| Benefits Administration Forms | Organizational Development | HR Support Forms |

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| Enterprise Learning Management (ELM) Forms |

Benefits Administration Forms

• COBRA
  
  

  
   COBRA Initial Notice
  This explains the eligibility requirements to be enrolled in COBRA.
   
  Important Notice About Your Health Care Benefits Upon Separation
  
  
   

• Dental/Vision
  
  

  • Delta Dental of Ohio Claim Form
    NOTE: If you seek treatment from a participating dentist, you do not need to print a claim form; the dentist will have a form and will submit it for you.
    
    
  • Dental and Vision Enrollment and Change Form (ADM 4720)(exempts)
    When you and your dependents become eligible for dental or vision coverage, complete this form and return it to your payroll office. See the Dental and Vision pages for more information.
    
    

• Disability Forms
  
  

  • Application for Disability Leave Benefits-Employee Statement (ADM 4310)
    This form is used only for an initial filing of benefits.
     
  • Application for Disability Leave Benefits-Employer Statement (ADM 4312)
    This is the employer's information and is to be attached to ADM 4310. This form is also used when the employee is requesting an extension of benefits. 
      
  • Disability Agreement (ADM 4313)
    This form is used when filing for disability as an advancement of Workers' Compensation.
    
  • Disability - Agency Disability Questionnaire
    This form is to be completed by the employer and should accompany all initial mental health-related disability claims being filed with DAS-Benefits Administrative Services-Disability.
    
  • Disability - Request for Appeal
    
  • Statement of Psychiatric Disability (ADM 4316)
    This form is to be used when filing for disability benefits for mental/behavioral health disability. This should be used in addition to ADM 4310.
    
  • Supplemental Report for Disability Leave -Employee Statement (ADM 4311)
    This form is to be used by the employee to request an extension of disability benefits.
    
  • Supplemental Report for Disability Leave-Employer Statement
    This form is to be completed by the agency and accompany the employee's Supplement Report for disability leave benefits being submitted to BAS.
    
  • Work Capacity Form (ADM 4317)
    This form is to be completed by the attending physician for use in transitional return to work. This may be used for either Worker's Compensation or Disability.
    

Eligibility     

• Affidavit of Common Law Marriage (ADM 4731)
  To enroll a common law spouse for benefits as described in the "Eligibility" section of the Health Care and Long Term Care handbook, complete and submit this form to your agency's payroll or personnel office.
  
  
• Affidavit of Dependent Status (ADM 4729)
  This affidavit should be completed by new employees who have dependents over the age of 19 who they wish to cover. For more information, see the Benefits Decision & Comparison Guide.
  
  
• Request to Extend Limiting Age for Mentally Retarded, Severely Mentally Ill or Physically Handicapped Dependent Child (ADM 4730) 

           Aetna     

• Aetna Request for Continuation of Medical Coverage for Disabled Student or Handicapped Child
  Aetna enrollees who have a handicapped dependent child who is 1.) between the ages of 19 and 23 and not a student, or 2.) over the age of 23 must complete this form and send it to Aetna per instructions on the form.  

          Paramount

• Paramount Handicap Child Member Form
  Paramount enrollees who have a handicapped dependent child who is 1.) between the ages of 19 and 23 and not a student, or 2.) over the age of 23 must complete this form and send it to Paramount per instructions on the form.
  
  
  The Health Plan 
     
• The Health Plan Handicap Child Member Form
  The Health Plan enrollees who have a handicapped dependent child who is 1.) between the ages of 19 and 23 and not a student, or 2.) over the age of 23 must complete this form and send it to The Health Plan per instructions on the form.
   
  
  Medical Mutual
    
• Medical Mutual of Ohio(Ohio Med) Handicap Child Member Form
  Medical Mutual of Ohio (Ohio Med) enrollees who have a handicapped dependent child who is 1.) between the ages of 19 and 23 and not a student, or 2.) over the age of 23 must complete this form and send it to Medical Mutual of Ohio (Ohio Med) per instructions on the form.
    
  
  United Health Care
    
• United Healthcare Handicap Child Member Form
  United Healthcare enrollees who have a handicapped dependent child who is 1.) between the ages of 19 and 23 and not a student, or 2.) over the age of 23 must complete this form and send it to United Healthcare per instructions on the form.
  

 Life Insurance

• Life Insurance (Basic) Beneficiary Designation/Change Form (SI 11210-645571)
  The Standard Insurance Company's fillable beneficiary form for exempt employees. Can be completed online, printed, signed and then mailed to The Standard Insurance Company at the address on the form.
  
  
  

• Life Insurance (Basic) Continuation Form (ADM 4302) (for laid-off employees)
  
  
  

• Life Insurance (Supplemental) Conversion Privilege Form (for exemts)
  Exempt emplyoees may use this form to convert their supplemental (employee-paid) term insurance to whole life insurance upon leaving active state employment.
  
  
  

• Life Insurance (Supplemental) Enrollment and Beneficiary Designation Form (for exempts)
  Union-represented employees should consult the Union Benefits Trust at 800-228-5088 for information. Click here for detailed information about using this form.
  
  

• Life Insurance, The Standard Insurance Claim Form (for exempts)
  This form should be used by beneficiaries to apply for benefits upon the death of a covered exempt State employee.
  
  

• Life Insurance, The Standard Insurance Dismemberment Claim Form (for exempts)
  This form should be used by exempt employees to file a work-related claim for loss of a limb, hearing or sight.
  
  

• Life Insurance, The Standard Accelerated Benefit Application (for exempts)
  This form may be used by exempt employees to apply for an advancement of benefits if diagnosed with a terminal illness.
  
  

• Life Insurance, The Standard Insurance Application for Portability (for exempts)
  This form should be used by exempt employees to apply for a continuation of their life insurance after leaving State employment.
  
  
  
  

• Medical Benefits
  
  
  

  • Medical Benefit Enrollment and Change (ADM 4717)
    Needed to initially enroll yourself and your dependents in a health care plan such as an HMO or the Ohio Med PPO. Also used to make changes throughout the year such as the addition of a newborn or adopted child, the removal of a dependent due to them reaching age 19, changing from family to single coverage, etc. For more information, see the Spring Edition Pathways publication.
    
    
    

• Pharmacy
  
  

  • Catalyst Rx Mail Order Registration & Prescription Order Form
    Use this form to register to use the Catalyst Rx mail order program provided by Immediate Pharmaceutical Services.
    
    
  • Catalyst Rx Direct Member Reimbursement Form
    Use this form to request reimbursement from Catalyst Rx for unpaid pharmacy claims.
    
    
  • Prescription Fax Form
    The Prescription Fax Form is a form that you can take to your physician's office during an office visit to have your physician fax your prescription to our mail service provider Immediate Pharmaceutical Services (IPS). This form must be faxed directly from your physician's office in order to be valid.
    
     

• Supplemental Benefits
  
  

  • Child Care Voucher Application
    
    
  • EZ Reimburse Card Transmittal Form
    This form should be used when mailing or faxing EZ Reimburse Card receipts.
    
    
    
  • 2008 Flexible Spending Account Enrollment Form
    Use this form to enroll in the Health Care Spending Account and/or Dependent Care Spending Account program. This form should be utilized for new hires and newly eligible employees until 01/01/09. NOTE: check the FSA Reference Guide for eligibility information.
    
    
    
  • 2009 Flexible Spending Account Enrollment Form
    Use this form to enroll in the Health Care Spending Account and/or Dependent Care Spending Account program. NOTE: check the FSA Reference Guide for eligibility information.
    
    
    
  • Flexible Spending Account Claim Form
    Use this form to request funds from your Health Care Spending Account and Dependent Spending account program.
    
    
    
  • Flexible Spending Account Direct Deposit Form
    Use this form to enable direct deposit into your checking or savings account of your Health Care Spending Account or Dependent Spending Account funds.
    
    
    

• Workers' Compensation
  
  

  • Accident or Illness Report (ADM 4303)
    This report should be completed if you are injured at work. For more details, see the Workers' Compensation Web page.
    
    
    

  • Calendar of Wages Paid (ADM 4741)
    This form is for agency use only. This form is used by the agency to report wages for lost time Workers' Compensation claims.

  •  OIL ExtensionRequest (ADM 4722)

  • SC/OIL Hourly Payment Request Form
    This form is to be used by an employee when requesting the use of SC/OIL on an hourly basis.  This form is to be used only if the employee is in a transitional work program.

  • Salary Continuation or Occupational Injury Leave Benefits
    To request either the Salary Continuation or OIL benefit, complete the ADM 4303 and check which benefit is being requested

  • OIL Appeal Outcome Form

•  Part-time Employment Calculation Report (ADM 4728)

  
  
  • Forms for Agency Use Only
    
    
    • Benefits Make-Up Form
      
    • Benefits Refund Form
      
    • Direct Payment Instructions
    • Direct Payment Form
      Benefits Direct Pay Form is to be completed and sent in with payments for Board and Commission Members, Military Leave payments, etc. 
       
    • Part-time Employment Calculation Report
      This form is used by the agency to report wages for lost time Workers' Compensation claims for Part-time employees.

   Organizational Development Forms

  Classification and Compensation
  

  • Position Description Processing
    • Position Description Authorization Form
    • Position Description Form
    • Position Description Change Form
    • List of Major Worker Characteristics 
    • Table of Organization Guidelines  
       
  • Position Specific Minimum Qualifications
    • MQ Conversion Table
    • Job Analysis Questionnaire
    • SME Instruction Form
    • WRIPAC Process Spreadsheet
    • WRIPAC Spreadsheet Instructions
    • PSMQ Submission Checklist

  Performance Management

  • Bargaining Unit Performance Review Forms
    • Clerical
    • Direct Care
    • Labor
    • Professional/Paraprofessional
    • Protective Services
    • Trades/Technical
    • Teachers
       
  • Exempt Performance Review Forms
    • Support Staff
    • Manager/Supervisor and Professional/Paraprofessional
       
  • Other Needed Forms
    • Goals and Objectives Attachment Form

  HR Support Forms
  

  
  

  Certificate of Records Disposal (ADM 3504)
  This form is used to certify the destruction or transfer of records according to an approved records retention schedule.
  
  

  Certification Eligible List (ADM 4267)
  This form is used to prepare a list of persons whose average standing on civil service exams make them eligible for a position in a specific grade or classification.
  
  

  Civil Service Application (GEN 4268)
  Application for job positions within the State of Ohio
  
  

  Declaration Regarding Material Assistance/Nonassistance to a Terrorist Organization
  This form serves as a declaration of the provision of material assistance to a terrorist organization or organization that supports terrorism as identified by the US Department of State Terrorist Exclusion List, and must be completed for each individual hired for employment.
  
  

  Electronic Compliance Review Form
  This form is used to conduct the annual Personnel Action compliance review for those agencies participating in the PA Decentralization program. 
  

  Electronic Records Release Form
  This form should be completed when an agency rehires an employee or receives an employee who has transferred from a different agency. It is used to "release" the employee's electronic records to the new agency.
  
  

  Employment Eligibility Verification Form (Form I-9)
  All U.S. employers are responsible for completion and retention of Form I-9 for each individual they hire for employment in the United States.
  
  Layoff/Displacement Form (ADM 4138)
  This form must be included with an employer's written notification to an employee of the employee's layoff or displacement.
  
  Notice of Proposed Intent to Layoff
  Agencies should complete and submit this memo to DAS when they are considering a staff reduction resulting from a layoff or abolishment of personnel.
  
  Ohio National Guard Prior Service
  Application to claim annual leave accrual credit for prior service in the Ohio National Guard.
  
  Order of Removal, Reduction, Suspension, Fine, Involuntary Disability Separation (ADM 4055)
  This form is still on NCR paper and still contains a distribution list. You may view this form on the Internet, however, you must order this form from State Printing.
  
  Personnel Action Cover Sheet
  During the Temporary Hiring Control, agencies are required to complete the PA Cover Sheet for all PAs submitted to the Governor's Office. To ensure proper routing, please return PAs for positions subject to the hiring controls to DAS State Services, and return PAs for positions exempt from the hiring controls to the initiating agency.
  
  Personnel Action Form (ADM 4100)
  A Personnel Action (PA) form is required to initiate and document any activity significantly affecting an employee in state service. 
  
                           PDF Version                                 Word Version
  
  Position Description (ADM 4107)
  The position description (PD) is the key document in determining the appropriate classification and status of a position. It serves as a descriptive of the major goals and worker activities of the position. The PD is to be filled out by an appointing authority or his/her designee.
  
  

  Position Description Authorization (ADM 4136)
  This form may be used by an appointing authority to authorize certain changes to a position description.
  
  

  Pre-hire Review (ADM 4174)
  This form provides a checklist of items that must be verified prior to submission of a personnel action form for a new hire, promotion or transfer.
  
  

  Prior Service Verification Form
  This form should be used by eligible employees who have prior service with the state or any political subdivision of the state, and who wish to have that prior service count as service with the state.
  
  

  Records Inventory Worksheet (ADM 3516)
  This form should be completed for each records series and includes information on record title and description, type of record, location of record, beginning and ending date of record, method of retention and suggested period of retention.
  
  

  Records Retention Schedule (ADM 3500)
  This form is completed for each record series and provides instructions for the disposal of the record series.
  
  Records Transfer List (ADM 3502)
  This form is completed for each record series and provides instructions for the transfer of the record series.
  
  Signature Authorization
  This form may be used by a Director to authorize certain employees in the agency to sign personnel action forms on his/her behalf.
  
  Supplemental Employment Agreement (ADM 4288)
  This form states that the newly highly employee will pay any child support payments required of him/her, and must be filled out as part of the new hire process.
  
  Supplemental Nepotism Statement (ADM 4173)
  This form states that the newly hired employee has no known or undisclosed relatives or business associates employed by the State of Ohio or any business interests which are involved with state business. This form must be filled out as a part of the new hire process.
  
  Unclassifed Service Explanation and Acknowledgment Form
  This form should be used by appointing authorities to provide unclassified employees with written information describing the nature of employment in the unclassified civil service.
  
  
  

  
  Payroll Administration Forms
  
  Adoption/Childbirth Leave Calculation Worksheet
  This form should be used to calculate the amount of basic and supplemental payments for employees who elect to take adoption/childbirth leave.
  
  Authorization for Direct Deposit (ADM 4280)
  This form enables employees to have their earnings deposited directly into their checking or savings accounts.
  
  Cancellation of Direct Deposit (ADM 4286)
  This form must be completed in order to cancel the direct deposit of your earnings. This authorizes the State of Ohio to cancel your Authorization for Direct Deposit..
  
  Cancellation of an EFT Check
  This form may be used to cancel the earnings for an employee and/or reimburse the manual pay account for the manual check.
  
  Change of Address (ADM 4058)
  This form is to be completed by an employee who has had a change of address. Upon receipt of this form, personnel officers should pull the employee's old address form and replace it with the updated form.
  
  Customer Information Request (CIR)
  This form may be completed by agencies to request information from the DAS/HRD Office of Payroll Administration. It may also be used by agencies to request changes to their OAKS setup after go live (i.e. schedules, tasks, time approvals, etc.).
  
  Disability Retirement Supplement Worksheet
  This worksheet may be used to calculate the amount of supplemental payments for which a disability retired employee may be eligible.
  

  Disability Worksheet
  This worksheet may be used to assist payroll officers in entering an employee's disability benefits into payroll.
  
  

  ePay Notification Form
  This form should be completed when an employee changes their decision to accept/decline electronic receipt of their paystub.
  

  Family Medical Leave Act (FMLA) Physician Certification Forms:

  Depending on the need for leave, these forms should be completed by the physician that treat the employee applying for FMLA leave benefits.

  
  

  • Employee's Serious Health Condition
    

  • Family Member's Serious Health Condition
    

  • Serious Injury or Illness of Covered Servicemember
    

  • Qualifying Exigency for Military Family Leave   

  Fine Calculation Worksheet
  This form should be used to calculate the amount of fine to be deducted from an employee's payroll record.
  
  Injury Pay Worksheet
  This form may be used by an agency to determine an employee's injury pay.
  
  Leave Donation Donor Application Form (ADM 4256)
  This form should be completed by the employee seeking to donate his/her leave to a fellow employee who is eligible to receive donated leave.
  
  Leave Conversion/Restoration Form
  This form may be used by any eligible separated employee seeking to have his/her accumulated leave balances paid out or retained for future restoration.
  
  Military Differential Worksheet
  This form may be used by an agency to determine a military employee's total monthly military pay differential.
  
  
  Organ Donor Physician Certification (ADM 4261)
  This form should be completed by the physician that treated the employee applying for organ donor leave.
  
  Overnight Hospitalization or Outpatient Surgery Certification
  This form should be completed by the physician that treated the employee who was hospitalized overnight or had outpatient surgery.
  
  Payroll Refund/Adjustment Form
  Use for any adjusment or refund processed through payroll
  
  Payroll Certification/Authorization (ADM 4150)
  At the time the direct deposit file is transmitted to the division, authorized agency personnel should use this form to certify that the payroll processes have been successfully completed.
  
  Poll Worker Leave Verification Form
  This form must be submitted to your supervisor on the first day you return after service as a judge of elections.
  
  Payroll Deduction Card (ADM 6307)
  This form should be used by an employee to authorize his/her payroll officer to make certain deductions from the employee's earnings.
  
  Request for Manual Attachment
  This form should be completed and should accompany an agency's request for manual attachment.
  
  Request for Leave (ADM 4258)
  This form may be used to request sick leave, vacation leave, leave without pay, bereavement leave, jury duty, personal leave, compensatory time off, witness duty leave, military leave, adoption childbirth leave, pending disability leave and pending workers' compensation leave.
  
  Request for Off-Cycle Manual Paycheck
  This form should be used to process a request for a manual paycheck for unpaid wages, disability leave benefits or disability leave supplements.
  
  Request for Reprint of W-2
  This form should be used by agencies to request DAS/HRD to reprint a W-2 for a specific employee.
  
  Request for a W-2 C
  
  Reversal or Return of Direct Deposit
  This form should be used by agencies to prevent or reverse the direct deposit of an employee's compensation.
  
  Special Retirement Breakdown
  If there is a problem with an employee's retirement contributions, this form may be necessary to effectuate a make-up of retirement benefits.
  
  Statement of Residency in a Reciprocity State
  Employers are required to have a copy of this form on file for each employee who is a resident of Indiana, Kentucky, West Virginia, Michigan or Pennsylvania receiving compensation paid in Ohio and who claims exemption from withholding of Ohio income tax.
  
  

  2005	IRS Version
  2004	IRS Version
  2003	IRS Version
  2002	IRS Version
  2001	IRS Version
  2000	IRS Version
  1999	IRS Version
  Blank Year Pre-2000	IRS Version

  W2TX Screen Layout
  This screen shot correlates various items appearing on the HR2k system to their relative Box on the W2 tax form.
  
  

  Withholding Exemption Certification
  Employees should use this certificate if the number of natural dependency exemptions increases or decreases.
  
  
  

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  Learning & Professional Development Forms
  
  

  Educational Benefit Tax Exemption Forms
  These forms should be completed by agencies and employees to assist with the determination as to whether specific tuition expenses are exempt from taxation.
  

  • Exempt Employees
    
  • Bargaining Unit Employees

  
  Human Resources Academy Course Equivalency Credit Form
  This form may be used by Human Resources Academy participants who feel they can document a significant amount of professional experience in a given functional area in order to equivalency out of taking an HRA class or course.
  
  Human Resources Academy Graduation Request Form
  This form should be completed if the HRA program requirements are met and the participant wishes to participate in the next graduation ceremony and/or receive a program certificate of completion.
  
  Online Registration Brochure
  Download a brochure with step-by-step instructions on how to electronically access the training registration system.
  
  Training & Development Training Application
  This form should be used by employees who are interested in applying for a training and development program, including Human Resources Academy (HRA), Ohio Certified Public Manager Program (OCPM), PASS, Essentials of Management, People Matter series, Project Management, etc.
  
  Exempt Professional Development Program Forms
  This form may be used to request reimbursement for certain tuition expenses and costs associated with certain professional development events. This form must be submitted 14 days prior to the beginning of the course/event.

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  Enterprise Learning Management (ELM) Forms
  
  
  ELM Security/Functional Request Form
  
  This form is used to request security and functional profile access to ELM 9.0.
  
  

  • ELM Security/Functional Instructions

  
  ELM Categories Request Form
  
  This form is used to request for a category to be added to ELM 9.0
  
  

  • ELM Categories Instructions

  
  ELM Learning Resources Request Form
  
  This form is used to request for additional Learning Resources to be added to ELM 9.0
  (examples of learning resources are facilities, equipment, and materials).
  
  

  • ELM Learning Resources Instructions

  
  ELM Catalog Items/Delivery Methods Request Form
  
  This for is used to request the creation of catalog items and delivery methods to be added to ELM 9.0.
  
  

  • ELM Catalog Items/Delivery Method Instructions

  
  ELM Learner Group Request Form
  
  This form is used to request the creation of a learner group to be added to ELM 9.0.

  • ELM Learner Group Instructions