Human Resources Forms

The following page includes many of the most common forms used by our office and by our benefit carriers. This list is not exhaustive; please reference the appropriate sections of the website for all related forms and documents.

Benefits Enrollment

• HR Connection—for domestic full- and part-time employees
• Benefits Enrollment/Change Forms
  
  • for Local 95 Employees [pdf]
  • for COBRA Participants [pdf]
  • for Retired Carnegie Mellon Employees [pdf]
  • for Employees on a Disability Leave of Absence [pdf]
  • for Expatriates in International Locations
  • for Local Employees in International Locations
    

Dependent Benefits Administration

• Domestic Partner Registration for Full-Time Faculty/Staff [pdf]
• Domestic Partner Registration for Part-Time Faculty/Staff [pdf]
• Request for ID Cards for Family Members [pdf]

Benefit Programs & Carrier Forms
(Note: See the carrier websites for most carrier forms.)

Health Insurance

• UPMC HRA Claim Form [pdf]
• Highmark Medical Claim Form [pdf]
• Highmark HRA Claim Form [pdf]—use BCC Claim Form
• Highmark Retiree Major Medical Claim Form [pdf]

International Health Insurance

• CIGNA Enrollment/Change Form [pdf]
• CIGNA Claim Form [pdf]
• InterGlobal Enrollment/Change Form [pdf]
• International Travel Registration Form—Qatar [docx]
• International Travel Registration Form—All Other Locations [docx]
• Aetna World Traveler Claim Form [pdf]

Prescription Drugs

• Caremark Mail Order Enrollment Form [pdf]
• Caremark Prescription Reimbursement Claim [pdf]
• CVS/Caremark Supplemental Retiree Coverage—Claim Form [pdf]

Vision

• Davis Vision Direct Reimbursement Claim Form [pdf]

Dental

• Standard Claim Form [pdf]

Life Insurance and AD&D

• Sun Life Beneficiary Designation Form [docx]

Spending Accounts

• Reimbursement Claim Form [docx]
• Electronic Funds Transfer (Direct Deposit) Request [docx]
• Extra MBI Debit Card Request [docx]

Paid Time Off

• PTO Tracking Worksheet [xls]

FMLA and Disability Leaves of Absence

• Application for Family and Medical Leave of Absence form [pdf]
• Certification for Employee’s Own Serious Health Condition [pdf]
• Certification for Family Member’s Serious Health Condition [pdf]
• Certification for Serious Injury or Illness of Covered Servicemember [pdf]
• Certification of Qualifying Exigency For Military Family [pdf]
• Return To Work Certification Form [pdf]
• Intermittent FMLA Tracking Form for Non-Exempt Employees [pdf]
• Intermittent FMLA Tracking Form for Exempt Employees [pdf]

Workers' Compensation

• Workers' Compensation Injury/Illness Forms Packet [pdf]—Supervisor Injury/Illness Report, Acknowledgement of Employee Rights & Duties, Information Form, and Medical Panel
  
• Return To Work Certification Form [pdf]

Tuition Benefits

• Employee or Dependent Tuition Benefits Application—apply via HR Connection
• Non-Degree Student Registration Form [pdf]

Retirement Accounts

• HR Connection—for SRA online, to increase or decrease SRA contributions
• TIAA-CREF Faculty and Staff Retirement Account (GRA) Enrollment Form [pdf]
• TIAA-CREF Supplemental Retirement Account (GSRA) Enrollment Form [pdf]
• Vanguard Enrollment & Change Form [pdf]
• Salary Reduction Agreement—401(k) [pdf]
• Salary Reduction Agreement—403(b) [pdf]
• Prior Service Credit Request [pdf]—to fill out if you already have a retirement plan
• TIAA-CREF Forms Download Center
• Vanguard Asset Transfer Form [pdf]

Child Care

• Cyert Center For Early Childhood Education Sliding Scale Application [pdf]
  

Staffing and Recruiting Forms

• FAAF: Faculty Affirmative Action Form [xls]
• Employee Self-Identification form—Use HR Connection
• Position Management Form [pdf] and Position Management Form [docx]
• Pay Adjustment Form [pdf] and Pay Adjustment Form [docx]
• Temporary Employment Service Temp Request
  
• Wage Determination Packet [doc]—for H1B visa status hires

Employee Management Forms

• Equipment Loan Statement of Understanding [.pdf]
• Intellectual Property Policy Agreement Form (see also: Policy)
• Performance Improvement Plan [doc]
• Performance Review Guidelines and Review Form for Managers [doc] (or download the pdf form)
  
• Employee Performance Self-Assessment Form [doc] (or download the pdf form)
  
• Provisional Period Performance Review Form [doc]
• Statement of Understanding of the Family Educational Rights and Privacy Act (FERPA) [pdf]

Equal Opportunity and Disability Services Forms

• FAAF: Faculty Affirmative Action Form [xls]
• Employee Self-Identification form—Use HR Connection
  
• Student Voluntary Disclosure of Disability Form [pdf]
• Verification of a Temporary Disability [pdf]
• Permission to Share Information Form [pdf]—for Carnegie Mellon to share information with others
• Release of Information Form [pdf]—for releasing disability test results to Carnegie Mellon
• Alternative Format Request Form [pdf]
• Intake/Accommodations Form [pdf]—to request specific accommodations from Human Resources
• Interpreter Request Form [pdf]
• Interpreting Service Evaluation [pdf]
• Request for Proctored Exam [pdf]