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Forms University-wide | Bloomington | A-Z Forms Index

University-wide Forms

ADA
Classification
Dependent Child
Domestic Partnership
Employee Relations
Employment
Fee Courtesy
FMLA
Grievance
Insurance
Health, Dental, Prescription
Mass Transit
Personal Profile
Retirement
Reward and Recognition
Salary
Tax Saver Benefit
Timesheets

aDa

Reasonable Accommodation Request and Documentation Form

Essential and Marginal Job Functions Worksheet

classification

Position Description

Dependent Child

Application/Affidavit to Establish Dependency by Guardianship

Certification of Disabled Dependent Child Eligibility

Certification of Eligibility for Dependent Child Age 19 or Older

Domestic Partnership

Affidavit of Domestic Partnership

Same-Sex Domestic-Partner Health Plan Benefit Tax Estimation Work Sheet

Certification of Tax-Qualified Dependents |

Termination of Domestic Partnership |

Employee Relations

Leaves for Military Families Request Form |

Employment

Authorization Form for Motor Vehicle Records Check (Risk Management)

Background Check Consent Form

INS Form I-9

Fee Courtesy

IU Fee Courtesy 2008-2009 Benefit Enrollment Form |

IU Fee Courtesy 2007-2008 Benefit Enrollment Form

IUHS Tuition Waiver Form |

fmla

FMLA Definition of Serious Health Conditions

FMLA Form 1 Leave Notice or Request Approval and Information

FMLA Form 2E Medical Certification for Employee

FMLA Form 2F Medical Certification for Family (of Employee)

FMLA Form 3 Release/Intent to Return to Work

FMLA Medical Recertification Request

FMLA Time Off Designation/Tracking Sheet

grievance forms

Grievance Form for Hourly Employees

Grievance Form for Professional and Non-union Support and Service Staff

Health, Dental & Prescription Plans

Medical Care

IU PPO Plus, IU PPO $900 Deductible and Blue Preferred POS Plans

Medical Claim Form (Anthem)

Retiree Health Care Enrollment Form (under age 65)

Prescription Plan

IU PPO Plus, IU PPO $900 Deductible, Blue Preferred Primary POS

Anthem Prescription Order Form
NextRx Prescription Claim Form

M-Plan Health Care Plan

Prescription Drug Program Direct Member Reimbursement Form

Mental Health and Chemical Dependency

IU PPO Plus and IU PPO $900 Deductible

Indiana University Psychiatric Management (IUPM) Claim Form

Dental Plan

Dental Claim Form (CIGNA)

Student Health Insurance

International Dependent Enrollment Form 2007-08

International Continuation Form - Fall 2008

International/SAA Temporary ID card

IU Health Center Claim Form

SAA/Fellowship Dependent Enrollment Form 2007-08

SAA/Fellowship Continuation Form - Fall 2008

Visiting Scholars and Dependents Enrollment Form 2007-08

Other

Affidavit of Eligible Spouse/Child Status

Insurance Plans

Long-term Disability Insurance

Group Long Term Disability Insurance Plan Enrollment Form |

Medical History Statement for Non-Indiana Residents

Medical History Statement for Residents of Indiana

Supplemental Life Insurance

Enrollment Form

Medical History Statement for Non-Indiana Residents

Medical History Statement for Residents of Indiana

Change of Beneficiary Designation

Basic Life Insurance Plan

Beneficiary Designation

Personal Accident Insurance (PAI)

Enrollment/Beneficiary Change |

Mass Transit

Pre-Tax Mass Transit Expense Claim form

Personal Profile Forms

Change Form, Personal Data

Personal Profile Form (ED)

Personal Profile Form (PS)

Personal Profile Form (PSA)

Retirement

IU Retirement Plan

Investment Company Change Form

Fidelity IU Retirement Plan Enrollment Form

TIAA-CREF IU Retirement Plan Enrollment Form

IU Retirement Savings Plan 457(b)

Salary Deferral Agreement Form

Fidelity Investments 457(b) Enrollment Form and Beneficiary Designation

Your 457(b) Enrollment Form (TIAA-CREF)

IUSERP

Investment Company Change Form

IU Tax Deferred Annuity Plan 403 (b)

Salary Deferral Agreement

Account Application Fidelity Investments 403(b) Custodial Account

Your GRSA Enrollment Form (TIAA-CREF)

Public Employee's Retirement Fund (PERF)

Investment Direction Form

REWARD AND RECOGNITION

Reward Plan Document

Recognition Plan Document

Salary

Mid-Year Salary Adjustment Form for Professional Staff
     -Standard form
     -Form to use with 5 or more funding sources

 

Tax Saver benefit (TSB) plan

TSB Claim Form

Direct Deposit Authorization/Termination form (TSB & HRA)

Dependent Care Flexible Spending Account Worksheet

Health Care Flexible Spending Account Worksheet (Nyhart)

See the Benefits Change Connection about making changes to your plan

timesheets

PAO and PAU Employee Timesheets

Exempt (PAE) Staff PTO Record Card

 

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Bloomington Forms

Classification and salary

Appeal Form
    Information

Employee Relations

Employee Written Authorization for Release of Personnel File(s)

Grievance Form for Appointed Service Maintenance Employees

Grievance Form for Appointed Support Staff

Staff Incident Report

Unsafe Working Conditions Form for SM |

Employment

Appointed Service Maintenance positions:

Employment Application | | RTF version also available

Work History Supplement

Hourly positions:

Employment Application | | RTF version also available

* HTML online form template for submitting to a database; available upon request

Education and Work History Supplement | | RTF version also available

New Employee Information Form

Appointed Staff Position Posting Request Form

Hourly Position Posting Request Form

Telephone Reference Check