Affirmative Action / Equal Employment Opportunity

• Complaint Information Form

Benefit Forms

Dental and Medical Forms:

• EZ Claim Form for Incentive PPO and Purdue 500
• PHCS Provider Referral Letter  
• Anthem Claim Form (Prescriptions)
• Anthem Mail Order Form (Prescriptions)
• Change in Family Status Form (medical)
  This effects core benefits only and does not effect voluntary benefits such as dental.
• Change in Family Status Form (dental)
  Coverage will start on the first of the month following the effective date of the change.
• Medco Mail Order Form (United Healthcare Prescriptions)
• Payroll Deduction Authorization Form

Flexible Spending Account (FSA) Forms:

• Dependent Care FSA Claim Form (PDF)
• Dependent Care FSA Claim Form (Excel)
• Health Care FSA Claim Form (PDF)
• Health Care FSA Claim Form (Excel)
• FSA Direct Deposit Authorization
• Auto Reimbursement Waiver/Election Form

Retirement Forms:

• How to Enroll in Tax-Deferred Annuities
• Salary Reduction Agreement Form - 403(b) Plan and 457(b) Plan
• Request for Estimate of Benefits
• Application for Waiver of TIAA/CREF Three-Year Waiting Period
• Voluntary Early Partial Retirement Form

Other Benefit Forms:

• Prudential Short Form Health Statement
• Disabled Child Physician’s Form
• VSP Out-of-Network Claim Form

Employee Information Forms

• Employee Information Form (Form 13)
• HR AAO Self-Identification Compliance Form

Employee Relations Forms

Performance Management Forms
(Word documents)

• Performance Improvement Plan
• Personnel Evaluation Template.2.08
• Core Elements of a Personnel Evaluation Process

Progressive Discipline

• Sample Verbal Reprimand
• Sample Written Reprimand
• Sample Work Improvement Plan
• Sample Immediate Suspension
• Sample Suspension
• Sample Letter of Termination
• PUC Threat Assessment Checklist

Employment Forms / Resources

Hiring Forms/Procedures Policy

• Flex Schedule Form
• Form 10 - Staff Position Description
• Form 9 - Request to Establish a New Position or Fill an Existing Position
• Form 11 - Hiring Recommendation Form
• Search Guidelines
• Compensation Structure for Graduate Staff Appointments
• Position Vacancy Notice
• Graduate Staff Notice of Appointment

Onboarding (New Employee Forms)

• Faculty-Staff Parking Application (2007-08)
• Faculty-Staff Parking Application (2008-09)
• Limited-Term Lecturer/Graduate Assistant Parking Application (2008-09)
• Employment Eligibility Verification I-9
• Key Request Form
• Request for Privileges Form
• Career Account Instructions
• Request Form for Novell Account (Form 51)
• Documents Required for Processing a New Hire (Excel)

Personnel Action Forms (PA) and Contracts:

• Personnel Action (PA) Form
• Fellowship Action (FA) Form
• Personnel Change (PC) Form
• Appointment to the Faculty (Form 19)
• Lecturer Appointment Form (Form 19L)
• Non Renewal of Contract Notice Form 19E

Fee Remission Forms (Calumet)

• Application for Administrative / Professional / Faculty / Clerical / Service Fee Remission
• Application for Staff Dependent or Staff Spouse/Domestic Partner Fee Remission
• Application for Graduate Staff Fee Remission
• Application for Senior Citizen Fee Remission

Fee Remission Forms (IUPUFW)

• Staff, Staff Child, Staff Spouse/Domestic Partner and Graduate Student Staff fee remission form

Fee Remission Forms (North Central)

• Staff Child or Staff Spouse/Domestic Partner fee remission form
• Staff fee remission form

Fee Remission Forms (West Lafayette)

• Staff Child or Staff Spouse/Domestic Partner fee remission form
• Staff and Graduate Student Staff fee remission form (complete Section 9 of the Course Registration Form 23)

Leave Forms (Other)

• Form 33ABSENCE (PDF)
• Form 33ABSENCE (Excel)
• Form 33F (PDF)
• Form 33F (Excel)
• Leave Action Form (Excel)
• OnePurdue Leaves Reference Grid

OnePurdue Resources:

• New Pay Schedule Estimator (Excel)
• List of PUC Campus Org Unit Numbers (Excel)

Payroll / Timekeeping Forms:

• Federal Tax Form (W-4 / 2008)
• Indiana Tax Form (WH-4)
• Quota Correction Form
• Direct Deposit Application
• Pay Advance Enrollment Form
• Request for Flexible Schedule
• Summer Savings Enrollment Form
• Quota Payout Request Form
• OnePurdue Timecard

Worker’s Compensation Policy (Reporting Injuries)

• First Report of Injury

Other Helpful Links

• Purdue Policy & Procedures
• Purdue Business Processes
  (Business @ Purdue)