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Human Resources Division Downloadable Forms

The forms below are currently available online from the Human Resources Division.

Benefits Administration Forms

• COBRA
  
  
  • COBRA Eligibility Notification (ADM 4750)
    This form can be used once an employee leaves State employment and wishes to continue health care coverage.
    
    
  • COBRA Initial Notice
    This explains the eligibility requirements to be enrolled in COBRA.
    
    
• 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
  
  
  • Aetna Handicap Child Doctor Form
    Aetna HMO enrollees who have a handicapped dependent child over age 23 must have the attending physician complete this form. You should send it to Aetna along with the member form (below) per instructions on the form.
    
    
  • Aetna Handicap Child Member Form
    Aetna HMO enrollees who have a handicapped dependent child over age 23 must complete this form annually and send it to Aetna per instructions on the form. The doctor form (above) must also be sent back to Aetna.
    
    
  • 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)
    
    
• 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 Benefits Decision Comparison Guide.
    
    

• Pharmacy
  
  
  • Catalyst Rx Mail Order Registration & Prescription Order Form
    Use this form to register to use the Catalyst Rx mail order program provided by Walgreens Mail Service.
    
    
• Supplemental Benefits
  
  
  • Child Care Voucher Application
    
    
  • EZ Reimburse Card Transmittal Form
    This form should be used when mailing or faxing EZ Reimburse Card receipts.
    
    
  • 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.
    
    NOTE: This form's reference to the November 30, 2007 enrollment form submission deadline and the debit card reference are specific to open enrollment. These do not apply to individuals who may qualify to enroll in Flexible Spending Account Benefits at other times of the year.
    
    
  • 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.
    
    
    • Occupational Injury Leave
      The following three forms are to be completed and sent to the third party administrator by the employing agency for an initial request for OIL benefits.
      
      • Appointing Authority Report (ADM 4723)
        
        
      • Attending Physician Statement (Initial Treatment) (ADM 4721)
        
        
      • Employee's Application (ADM 4743)
        

    The following three forms are to be completed and sent to the third party administrator when an extension of OIL benefits is being requested.

    • Employee's Extention Request (ADM 4722)
      
      

    • Supplemental Employer Statement (ADM 4726)
      
      

    • Supplemental Physician's Statement (ADM 4725)
      
      

• Forms for Agency Use Only
  
  

• Benefits Make-Up Form
  
  
• Benefits Refund Form
  
  
• 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.
  
  

Class & Compensation Forms

• Performance Review Forms
  These forms and their performance dimensions have been designed to "group" classifications that have the same or similar work functions. They cover the employee groups listed below, and separate forms have been developed for bargaining unit and exempt employees.
  

Bargaining Unit Labor (ADM 4270)

Bargaining Unit Professional/Paraprofessional (ADM 4271)

Bargaining Unit Clerical (ADM 4272)

Bargaining Unit Direct Care (ADM 4273)

Bargaining Unit Protective Services (ADM 4274)

Bargaining Unit Trades/Technical (ADM 4275)

Bargaining Unit Teachers (ADM 4276)

Exempt Administrative Support (ADM 4281)

Exempt Manager/Supervisor and Professional/Paraprofessional (ADM 4282)

Goals and Objectives Attachment Form (ADM 423)
This form should be utilized by the employee and his/her manager during the OPERS goal-setting process. Both the supervisor and employee must sign this form, indicating their agreement to the goal established and the measurement described.

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 1-9)
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. On the form, the employer must verify the employment eligibility and identity documents presented by the employee and record the document information on the Form I-9.

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.

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.

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.

Request for Expanded Computer Access
This form serves as a request form for those agencies participating in PA decentralization to allow for computer entry and approval capabilities for the position control sub-system.

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 (ADM 4260)
This form should be completed by the physician that treat the employee applying for Family Medical Leave Act (FMLA) benefits.

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.

OAKS Time and Labor Self-Service Security Application
This completed form requires the approval of the requesting agency HR Administrator or designee (OAKS Agency Security Contract). OAKS will only process approved requests received from the authorized Agency Security Contact.

OAKS HCM User Security Access Request Form
This request overrides a user's current access to the OAKS system or creates access for a user that does not have access.

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 Physician Certification (ADM 4262)
This form should be completed by the physician that treated the employee who was hospitalized overnight.

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 W-2C
This form should be used by agencies to request DAS/HRD to issue a W-2C for a specific employee.

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. Reprints will be mailed directly to the employee's mailing address on record.

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.

W-2 Wage and Tax Statements

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.

Training & Development Forms

Blueprint for Lifelong Learning Catalog
2006-2007 catalog of classes offered for the continuous improvement and professional development of Ohio employees.

Computer Purchase Application
Exempt employees should use this form to download the application for an interest free loan of up to $1800 to purchase a computer and/or computer equipment.

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.

Employee Computer Purchase Addendum
This form may be used to change the payment terms of an employee's computer purchase agreement.

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.

Ohio Certified Public Manager Exact/Comparable Substitution Form
This form may be used by Ohio Certified Public Manager (OCPM) program 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.

Ohio Certified Public Manager Program Participant Withdrawal Form
This form should be used by employees who are interested in withdrawing from the OCPM program.

Ohio Certified Public Manager Program Participant Exit Form
This exit evaluation form should be completed by program participants to monitor the effectiveness of the program and will be used to improve the program.

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.

Tuition & Events Reimbursement Application
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.