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.

The majority of documents on this page are in Adobe PDF format. You will need a current (version 7 or later) version of Acrobat Reader to access these documents. Adobe's Acrobat Reader is available for download at no cost from http://www.adobe.com/products/acrobat.

Benefits Enrollment

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

Dependent Benefits Administration

• Domestic Partner Registration Packet for Full-Time Carnegie Mellon Faculty and Staff (.pdf)
• Domestic Partner Registration Packet for Part-Time Carnegie Mellon Faculty and Staff (.pdf)
• Student Status Verification (HR Connection) - to cover children age 19 up to 23 who are full time students
• Request for ID Cards for Family Members (.pdf) - must be a declared dependent or registered domestic partner.

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

Health Insurance

• UPMC HRA Claim Form (.pdf)
• HealthAmerica FlexChoice HRA Claim Form (.pdf)
• Highmark Medical Claim Form (.pdf)
• Highmark HRA Claim Form (.pdf) - use EBDS 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 (.doc) - to acquire Aetna World Traveler coverage
• Aetna World Traveler Claim Form (.pdf)

Prescription Drugs

• Caremark Mail Order Enrollment Form (.pdf)
• Caremark/PharmaCare Direct Member Reimbursement Form (.pdf)
• Merck-Medco Health, Allergy & Medication Questionnaire (.pdf)

Vision

• Davis Vision Direct Reimbursement Claim Form (.pdf)

Dental

• Standard Claim Form (.pdf)

Life Insurance and AD&D

• MetLife MyBenefits website - to complete beneficiary designation
  
• Beneficiary Designation Form (.pdf)
• MetLife Statement of Health Form (.pdf)

Spending Accounts

• EBDS HCFSA and DCRA Claim Form (.pdf)
• EBDS Direct Deposit Form (.pdf)

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)

Workers' Compensation

• Workers' Compensation Forms (.pdf) - Supervisor Injur/Illness Report, Acknowledgement of Employee Rights & Duties, and Information Form
  
• Return To Work Certification Form (.pdf)

Tuition Benefits

• Employee or Dependent Tuition Benefits Application - apply via HR Connection
• Student Status Certification - certify via HR Connection
  
• Non-Degree Student Registration form (.pdf)

Retirement Accounts

• HR Connection - for SRA online, to increase or decrease SRA contributions
• New Supplemental Retirement Account - Salary Reduction Agreement (.pdf)
• TIAA-CREF Faculty and Staff Retirement Account (GRA) enrollment application (.pdf)
• TIAA-CREF Supplemental Retirement Account (GSRA) enrollment application (.pdf)
• Vanguard Enrollment & Change Form (.pdf)
• Plan Change for University Contributions form (.pdf)
• Prior Retirement Plan Participation form (.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)
  
• Get Well Room: Fact Sheet, Health Assessment Form and Registration Form (.pdf)

Staffing and Recruiting Forms

• FAAF: Faculty Affirmative Action Form (.xls)
• Employee Self-Identification form (.pdf) - to self identify as disabled, a disabled veteran, or a Vietnam veteran.
• Position Management Form (.pdf) and Position Management Form (.doc)
• Pay Adjustment Form (.pdf) and Pay Adjustment Form (.doc)
• Staff Diversity Recruiting Action Plan (.doc)
• Temporary Employment Service Temp Request Form
• 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 format)
  
• Employee Performance Self-Assessment Form (.doc) (or download the PDF format)
  
• 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 (.pdf)
• Student Voluntary Disclosure of Disability form (.pdf)
• Verification of a Disability/Parking (.pdf) - to request special parking services
• 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)