Affidavit of Eligible Spouse/Child Status

Affidavit of Domestic Partnership

Application/Affidavit to Establish Dependency by Guardianship

Certification of Disabled Dependent Eligibility

Certification of Tax-Qualified Dependents - Domestic Partner Benefits

Affidavit of Domestic Partnership

Certification of Tax-Qualified Dependents

Same-Sex Domestic-Partner Health Plan Benefit Tax Estimation Work Sheet

Termination of Domestic Partnership

Termination of Tax-Qualified Dependent Status

Statement of Facts Supporting Reasonable Cause of Drug or Alcohol Use by Employee

Employee Authorization and Consent to Submit to Substance Abuse Testing

Employee Refusal to Submit To Substance Abuse Testing

Highlights of a Conditional Employment Agreement

Request for Alcohol/Drug Screening (campus-specific form and procedures at Office of Insurance, Loss Control & Claims site - click Drug & Alcohol Screening under Procedures)

Authorization Form for Motor Vehicle Records Check (Office of Insurance, Loss Control & Claims)

Background Check Consent Form

Employee Referral Incentive Validation Form

Essential and Marginal Job Functions Worksheet (Word doc)

I-9 Form and Instructions

Reasonable Accommodation Request and Documentation Form

Request for Seasonal Employment of Temporary Employee (requires IU logon)

Staff Position Posting Request Form (web form, goes to University OLA staff side)

Bloomington:
Telephone Reference Check

Temporary Positions Employment Applications

Application

Background Check Consent Statement

Work History Supplement

Family Status Change (OneStart)

Employee Written Authorization for Release of Personnel File(s)

Personal Profile Forms

Change Form, Personal Data
Update personal information already on file (legal name, marital status, SSN, etc.)

Personal Profile Form (ED)
Must be completed by the newly hired employee

Personal Profile Form (PS)
For the employee to identify prior work experience, professional education, licenses etc.

Personal Profile Form (PSA)
To be completed by the employee who wants to be identified as a person with a disability

Grievance

Professional and Non-union Support and Service Staff

Temporary Employees

Bloomington and Northwest
Support Staff

Bloomington, IUPUI, and South Bend:
Service Employees

Bloomington, IUPUI, Northwest, South Bend, and Southeast
Police Service Employees

Staff Report

Bloomington:
Staff Report (Word doc, for long documents)
Staff Report (PDF, for short documents)

Dental

CIGNA Dental Claim Form

Medical

Anthem Medical Claim Form (HDHP PPO, PPO $900, & PPO $500 plans)

IU Health Medical Claim Form (IU Health HDHP plan)

IU Health Center Claim Form (student health insurance only)

Prescription

Prescription Drug Claim Form

Prescription Drug Mail Order Form

Prescription Drug Refill Request Form

Basic Life Insurance

Beneficiary Designation

Long-term Disability Insurance

Claim Packet

Enrollment form (Also available as a web form)

Medical History Statement

• Indiana Residents
  
• Michigan Residents
• AR, CO, DC, KY, LA, NJ, NY, OH, PA, TN Residents
• All Other States Residents

Personal Accident Insurance (PAI)

Beneficiary Designation

Enrollment form (web form)

Supplemental Life Insurance

Beneficiary Designation

Enrollment Form (Also available as a web form)

Medical History Statement

• Indiana Residents
  
• Michigan Residents
• AR, CO, DC, KY, LA, NJ, NY, OH, PA, TN Residents
• All Other States Residents
  

Approval Form for a Leave for Development of Commercial Projects with a Non-University Entity

FMLA (Family and Medical Leave Act)

Certification of Qualifying Exigency for Military Family Leave (PDF)

Certification for Serious Injury or Illness of Covered Service Member (PDF)

FMLA Definition of Serious Health Conditions (PDF)

FMLA Form 1 Leave Notice of Designation, Request, & Approval (PDF)

Essential and Marginal Job Functions Worksheet (Word doc)

FMLA Form 2E Medical Certification for EMPLOYEE (PDF)

FMLA Form 2F Medical Certification for FAMILY (PDF)

FMLA Form 3 Intent to Return and Fitness for Duty/Medical Release (PDF)

Medical Recertification Request (PDF)

Tracking Sheet (PDF)

Military Leaves

Leaves for Military Families Request Form (PDF)

Verification of Military Service or Training (PDF)

PERF

See the INPRS web site for PERF forms

Salary Deferral Agreements

IU Retirement Savings Plan 457(b)

IU Tax Deferred Account (TDA)

Employee Recognition Award Plan

Employee Referral Incentive Validation Form

Incentive Pay or Commission Plan

Position Description Form (web form)

Request for Reconsideration of Position Classification (Word doc)

Employee Checklist

Supervisor Checklist

IU Health Center Claim Form (PDF)

See the Student Health Insurance web pages for forms specific to each plan

Health Savings Account (HSA) Enrollment/Change Form

Pre-Tax Commuting Expense Claim Form

Tax Saver Benefit (TSB) Plan

TSB Healthcare and Dependent Care Claim form

Dependent Care Flexible Spending Account Worksheet

Direct Deposit Authorization/Termination form

* See the Benefits Change Connection about making changes to your plan

Online IU Tuition Benefit Enrollment Form (Also available as a PDF)

IUHS Tuition Waiver Form (Also available as a web form)

Service Maintenance positions Bloomington:
Unsafe Working Conditions (Also available as a Word doc)