Please note: Unless otherwise indicated, the documents on this page are provided in Portable Document Format [PDF]. If you are unable to utilize PDF files, please contact Human Resource Services for information on the availability of alternative formats and/or to set up an appointment for personal assistance (contact information included below).

Adobe® Reader v4.x or higher is required to view PDF files downloaded from the HRS Web site. However, downloads indicated as being offered from external sites [i.e., UT System] may require a higher version. If you are not familiar with using PDF files --or-- if you need to download a free copy of Adobe Reader, please read the important information at the bottom of this page. You may also want to check out the Printing Tip.

Downloadable Documents	Need Assistance?
Insurance Forms Insurance Enrollment/Status Change Forms Insurance Rates Evidence of Insurability (EOI) Forms Medical/Pharmacy/Dental Forms Term Life/Accidental Death & Dismemberment Forms Insurance Claim Forms UT Flex Forms	Benefit Services [512-471-4772]
Leave Forms Family Medical Leave Forms Sick Leave Pool Forms Leave of Absence Request	Leave Management [512-232-2327]
Workers' Compensation Insurance Forms Return to Work Forms Social Security Number Disclosure	Workers' Compensation [512-471-3133]
General Employee Forms	Employee Records [512-471-5127]
Employee Performance Evaluation	Employee Relations [512-232-2327]
HR Publications	Training Services [512-471-5045]
Compliance Posters	Compliance and Campus Relations [512-232-2444]

Insurance Forms

Note: Links for downloading Insurance Plan Booklets are available on the HRS Benefit Services Insurance page.

Insurance Enrollment/Status Change Forms

Dependent Information Form [38K]

Employee Insurance Enrollment/Change Application 2007-2008 [62K]

ORP Declaration of Retirement for Group Insurance Purposes [14K]

Retiree Insurance Enrollment/Change Application [63K]

Automatic Payment Request Authorization Form for Retiree Insurance

Insurance Rates

Benefit Cost Worksheet - 2007-2008 [Automated and Printable Forms; UT System Web site]

COBRA Premium Rates - 2007-2008 [15K]

Evidence of Insurability (EOI) Forms

Long/Short Term Disability Evidence of Insurability Form [48K]

UT Select Medical/Life Evidence of Insurability Form [235K]

Medical/Pharmacy/Dental Forms

Assurant Primary Family Dentist Selection Form [120K]	BlueCross BlueShield Provider Nomination Form [83K]
BlueCross BlueShield Transitional Benefits Form [148K]	UT Select Medco Pharmacy Order Form [UT System Web site]

Term Life/Accidental Death & Dismemberment (AD&D) Forms

Term Life/AD&D Beneficiary Designation Form [65K]

Insurance Claim Forms

Assurant Dental Claim Form [64K]	Delta Dental Claim Form [Delta Dental Web site]
HIPAA Forms [UT System Web site]	UT Select Claim Form [BlueCross BlueShield Web site]

UT Flex Forms

Claim Form [46K]	Direct Deposit Authorization Form [117K]
Enrollment Form [124K]	Letter of Medical Necessity [36K]

Leave Forms

Family Medical Leave Forms

Additional FMLA Documentation [html]	Certification of Health Care Provider [external site]
Designation for Family Medical Leave [67K]	Medical Records Release [3K]

Sick Leave Forms

Sick Leave Pool Application [96K]

Sick Leave Pool Transfer Form [40K]

Leave of Absence Forms

Leave of Absence Request [18K]

Workers' Compensation Insurance Forms

Return to Work Forms

Employee Guidelines [37K]	Letter to Treating Physician [15K]
Offer Letter [12K]	Supervisor Guidelines [38K]

Social Security Number Disclosure

Notice to Employees [38K]

General Employee Forms

Annual Request for Outside Employment [Provost Web site]	Employment Eligibility Verification (Form I-9) [external site]
Employee Information Form [252K]	Employee Separation Form [94K]
Ethics Statement [37K]	Ethics Statement in Spanish [27K]
PO-14 Form (Student/Non-Benefits Eligible Employment Application) [74K]	Background Check Request Form [39K]
Security Sensitive Position Applicant Identification Verification [48K]	Selective Service Eligibility & Verification Form [23K]
SSN Acknowledgment [35K]	Telecommuting Agreement [223K]
Time Report [43K]	Time Report for Hourly Employees [46K]
Transfer of State Service Credit & Leave Balances [29K]	Veteran Status Form [126K]
See also Payroll Services for additional forms (i.e., PO8, W-4, Savings Bonds, etc.)

Employee Performance Evaluation

Performance Evaluation Form - MS Word [for Macintosh and Windows]

Human Resource Publications

HRS Training Calendar [html]

Compliance Posters

USERRA [US Department of Labor Web site]

IMPORTANT INFORMATION ABOUT PDF FILES:

Unless otherwise indicated, all forms and informational documents on this page are "PDF" (Portable Document Format) files. To view these files, you will need to have at least version 4 of the Adobe® Reader installed on your computer.

Please note: Files indicated as being provided by UT System, or other HRS-external sites, may require higher versions of the Adobe Reader. If you encounter problems with opening a PDF file, you may need to upgrade your Reader.

The current version of the FREE Adobe Reader application, as well as installation and usage information, is available from Adobe's Web site.

Download Adobe® Reader

PRINTING TIP:

Several of the documents included on this page use very narrow print margins. If you have problems with the edges of the document being "cut off" by your printer, select the "Shrink to fit" or "Fit to Paper" option in the Acrobat Print dialog box. This option will proportionally reduce the document so that it will fit within the printable area for your printer.

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