Forms

Benefits  |  Campuswide Standing Committees  |  Classification/Compensation
Employee Information Update  |  Evaluation/Performance Appraisal  |  Employee Fee Waiver
Employment Actions  |  Leave of Absence  |  Outstanding Staff Nomination  |  Recruitment  | 
Separation/Early Settlement  |  Telecommuting  |  Volunteers  |  Workers' Compensation

Many of these forms are in Adobe PDF or Microsoft Word format. If you are experiencing problems when trying to open any of these forms, please visit the download links provided here to obtain the latest versions of the reader software.

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• Microsoft Word Viewer

Benefit Forms

(Open Enrollment Forms are on Benefits home page)

• Affidavit of Gender Verification for Married Employees [pdf]
• Beneficiary Designation for Cal Poly paid Life Insurance[pdf]
• Claim form for HCRA/DCRA [Word] [pdf]
• Claim forms for PERS Choice, PERS Select, PERS Care plans [pdf]
• Claim form for VSP vision plan - Out of Network Reimbursement [pdf]
• Claim form for VSP vision plan video display terminal (computer glasses) for employees working on a computer 4 or more hours per day[pdf]
• Domestic Partner Tax Dependent Certification [pdf] rev. 12/04
• Enrollment Worksheet for Benefit Elections and/or Changes [pdf fill-in] and companion document, PERS Declaration of Health Coverage [pdf fill-in]
• Voluntary Life Insurance Enrollment, Beneficiary, Claim and Conversion Forms through The Standard

Campuswide Standing Committees

• Application Form [Word] rev. 11/08

Classification & Compensation

• HR IRP Procedures and Form for Requesting In-Range Progression CSUEU Employees [Word] rev. 06/07
• HR 120 – Position Description [Word] rev. 11/08
• HR 120 Guidelines [pdf]

Employee Information Update

• Employee Self Service
• Personal Data Form [Word] [pdf] rev. 09/09
• Designation of Person Authorized to Receive Warrants - must be submitted to Human Resources in person with picture ID. [pdf]

Employment Actions

• HR101 Staff/MPP Personnel Action Request Form [pdf] rev. 04/08
• HR 101 Guidelines [pdf]
• HR101-S Additional Employment Agreement Form [pdf]
• HR Form E Staff/MPP/Non Tenure-Track Faculty Personnel Action Exemption Approval Form [Word] rev. 06/09

Evaluation/Performance Appraisal

• Annual Staff Employee Evaluation Cycle Grid for Performance during FY 2008-09 [Word]
• HR 136a Management Employee Self-Evaluation [Word] [pdf] rev. 5/02
• HR 136 Performance Planning and Appraisal for Mgmt Personnel [Word] [pdf] rev. 04/04
• HR 138 Staff Performance Appraisal [Word] [pdf] rev. 08/02
• HR 138a Staff Employee Self-Evaluation [Word] [pdf] rev. 05/00
• HR 140 Unit 4 Report of Employee Performance with instructions for completion [Word]

Fee Waiver

Employee Fee Waiver Forms

• HR 133 Employee Fee Waiver Course Notification [Word] rev. 10/08
• HR 133a Employee Fee Waiver Program – Individual Career Development Plan [Word] [pdf] rev. 6/02
• HR 133b Employee Fee Waiver Program – Change of Courses [Word] rev. 9/06

Dependent Fee Waiver Forms

• HR 133c Dependent Fee Waiver [Word] rev. 10/08
• HR 133d Disabled Dependent Benefit [pdf]
• HR 133e Affidavit of Eligibility for Economically Dependent Children [pdf]

Outstanding Staff Nomination

• Nomination Procedures and Form [Word] rev. 01/09
• Reference Form [Word] rev. 11/08

Recruitment

• For Hiring Department Information and Forms, please see the Hiring Information channel on the Cal Poly portal.

Separation/Leave of Absence/Early Settlement

• HR 190/190a Application for Leave Without Pay; Election of Direct Payment of Benefits While on Leave Without Pay; Procedures (Staff & MPP) [Word] [pdf] rev. 1/08
• HR 190a Election of Direct Payment of Benefits While on Leave Without Pay (Faculty) [Word] [pdf] rev. 5/06
• HR 191 Resignation Form [Word] [pdf] rev. 01/09
• PR 192 Faculty Early/Final Settlement Authorization [Word] [pdf] rev. 5/06
• PR 193 Tax Deferred Contribution from Final or Vacation Settlement Pay [pdf]
• PR 300 Employee Separation Form [Word] [pdf] rev. 09/09
• Timelines and information about The Retirement Process [Word]

Telecommuting

• HR 400 Telecommuter's Agreement [Word] rev. 06/06
• Telecommuting Guidelines [Word] rev. 06/06

Volunteers

• V-1 Volunteer Identification Form [[pdf]] rev. 10/08
• Read Volunteer Instructions before completing form. [[pdf]] rev. 4/09

Workers' Compensation

• Work Related Injury/Illness Procedure and Forms (includes Process, Supervisor's Form and DWC1) [pdf] rev. 05/09
• Form 104-B Predesignation of Physician [pdf] rev. 10/08
• Form 105-C Designation of Personal Chiropractor [pdf] rev. 10/08

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