Forms

Medical Forms:

• EZ Claim Form for Incentive PPO and Purdue 500
• PHCS Provider Referral Letter  
• Anthem Claim Form
• Anthem Mail Order Form
• Medco Mail order form

Flexible Spending Account (FSA) Forms:

• Dependent Care FSA Claim Form (PDF)
• Dependent Care FSA Claim Form (Excel)
• Health Care FSA Claim Form (PDF)
• Health Care FSA Claim Form (Excel)
• FSA Direct Deposit Authorization
• Auto Reimbursement Waiver/Election Form

Retirement Forms:

• Salary Reduction Agreement Form - 403(b) Plan and 457(b) Plan
• Request for Estimate of Benefits
• Application for Waiver of TIAA/CREF Three-Year Waiting Period

Other Benefit Forms:

• Change in Family Status Form (medical)
  This effects core benefits only and does not effect voluntary benefits such as dental.
• Change in Family Status Form (Grad Staff Medical) This form is for Graduate Staff Medical only
• Change in Family Status Form (dental)
  Coverage will start on the first of the month following the effective date of the change.  
• Prudential Short Form Health Statement
• Worker's Compensation Reporting Form 
• Worker's Compensation Witness Report Form
• Disabled Child Physician's Form
• VSP Out-of-Network Claim Form

• Performance Planning Worksheet 
• Performance Coaching and Feedback Worksheet 
• Performance Summary 
• Development and Career Planning Worksheet 
• Feedback for My Supervisor Worksheet 

Employee Information Forms (Form 13)

• About the Employee Information Forms
• Form 13

• Self Identification Compliance Form

Employment and Compensation Forms 

• Staff Position Posting Form only
• Temporary Position Request
• Employment Eligibility Verification I-9
• Flex Schedule Form

OnePurdue Forms

• effective dates: June 11 - 15
  Release 2 HR Data Validation
  Corrections Worksheet

Org Management Forms:

• Business Processes and all Forms
• Interdepartmental Position Guidelines
• Forms only
  • Continuing Lecturer Position Request
  • Faculty Position Request
  • Fellowship Position Request
  • Grouped Position Request
  • Staff Position Description
  • Supervision Roster
  • HR Organizational Unit Creation/Maintenance

Personnel Action Forms:

• Personnel Action (PA) Form
• Fellowship Action (FA) Form
• Personnel Change (PC) Form
• Documents Required to Process Appointment Actions
• Student Hiring Form - optional
• Contract Form 19
• Contract Form 19L
• Non Renewal of Contract Notice Form 19E
• Additional Pay Request Form
• Cost Override form