Ohio Department of Health
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 Human Resources Division - Downloadable Forms

Benefits Administration Forms


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.

Benefit Enrollment/Change Form (ADM 4717) (exempt employees)
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.

Union Benefits Trust

Disability Forms

Application for Disability Leave Benefits-Employee Statement (ADM 4310)
This form is used only for an initial filing or reinstatement 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 for Disability.

Disability - Request for Appeal

Statement of Psychiatric Disability Leave (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 DAS Benefits Administrative Services.

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.


Verification Form (NOTE: This form has been replaced by the Union Benefits Trust Dental & Vision Enrollment form under the Dental/Vision section above.)

Affidavit of Common Law Marriage (ADM 4731)
This affidavit should be used to enroll a common law spouse for benefits.

Affidavit of Student Status (ADM 4729)
This affidavit is to be completed when an enrolled dependent turns 19, a dependent is being enrolled in coverage or the document is requested during the course of an audit.

Handicap Child Member Form
The required form may be obtained from your agency benefits specialist. After completing the form, submit it to DAS HRD HCM Benefits via fax at 614-728-3002 (a secure fax) or via email at mybenefits@das.ohio.gov.

Life Insurance

For Exempt Employees
Securian Financial Group Life Insurance Enrollment Form
This form is to be used by eligible, exempt employees who want to enroll in supplemental life insurance coverage for themselves, their spouse or their children. Once an employee is eligible for basic life insurance (after one year of continuous service), enrollment is automatic and does not require an enrollment form.

Securian Financial Beneficiary Designation Form
This form is to be used by exempt employees who have basic and/or supplemental life insurance with Securian Financial.

If an employee has both basic and supplemental life insurance, the most recent beneficiary designation on file with Securian Financial will apply to both policies. Therefore, an employee cannot designate one beneficiary for one of the policies and a different beneficiary for the other policy.

For Laid-off Employees – Bargaining Unit and Exempt Employees
Life Insurance (Basic) Continuation Form (ADM 4302)

Medical Benefits

Benefit Enrollment and Change Form (ADM 4717) 
Needed to initially enroll yourself and your dependents in 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, changing from family to single coverage, etc. For more information, refer to the Pathways to myBenefits Open Enrollment edition.

Prescription Drug

OptumRx Mail Order Registration & Prescription Order Form
Use this form to register to use the OptumRx mail order program provided by OptumRx Home Delivery.

OptumRx Direct Member Reimbursement Form
Use this form to request reimbursement from OptumRx for unpaid prescription drug claims.

OptumRx Prescription Fax Form
The OptumRx 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 OptumRx Home Delivery. This form must be faxed directly from your physician's office in order to be valid. 

 Supplemental Benefits

Flexible Spending Accounts Guides

2021 Flexible Spending Accounts Reference Guide

Health Care Spending Account Forms

2021 Flexible Spending Accounts Enrollment Form

HCSA Pay Me Back Claim Form

FSA Health Care Spending Account Worksheet

FSA Change in Status Form

Limited Purpose Spending Account Form

Limited Purpose Spending Account Worksheet

Dependent Care Spending Account Forms

2021 Flexible Spending Accounts Enrollment Form

DCSA Pay Me Back Claim Form

FSA Dependent Care Spending Account Worksheet

FSA Change in Status Form

Click here to return to the Flexible Spending Accounts web page.

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.

Salary Continuation or Occupational Injury Leave Extension / Reactivation Request Form (ADM 4726)

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.

Salary Continuation/Occupational Injury Leave Hourly Payment Request Form
This form is to be used by an employee when requesting the use of Salary Continuation/Occupational Injury Leave on an hourly basis. This form is to be used only if the employee is in a transitional work program.

Salary Continuation and Occupational Injury Leave Appeal Form

Part-time Employment Calculation Report (ADM 4728)

HR Support Forms

Action/Reason Code Matrix

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

Civil Service Status Change Checklist - Revised 7-22-2013
Process of changing the Civil Service status from classified to unclassified or unclassified to Classified.

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.                                           

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, rehire, or transfer.

Prior Service Certification (pdf)

Prior Service Certification

Teacher Prior Service Certification (pdf)

Teacher Prior Service Certification

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.

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.

Unclassified Background Check Form A (Background Information)

Unclassified Background Check Form B (Disclosure Questionnaire)

Unclassified Background Check - Limited Tax Waiver Form

Unclassified Background Check Form - Instructions

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

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.

Disability Checklist

Disability Cover Letter

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 Pay Worksheet
Use this form to calculate disability pay.

Overpayment Form
This form should be completed when an employee receveives an overpayment of any kind.

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.

Leave Balance Adjustment Worksheet

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 Separation 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.

Military Leave Request
This form should be used in conjunction with military orders to indicate leave time and insurance while on military duty.

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

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 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 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:

Pre-2006 Retirement Breakdown
2007 - 2008 Retirement Breakdown
2009 - 2010 Retirement Breakdown
2011 - 2012 Retirement Breakdown
2013 - 2014 Retirement Breakdown
2015 - 2016 Retirement Breakdown

2017 - 2018 Retirement Breakdown
2019 - 2020 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.


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

Forms for Agency Use Only

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. 


Learning and Talent Development Forms

On-site Agency Training Request Form

For Agencies to request on-site training.