Forms
Adoption Reimbursement Form
Continuing Education
Dental Care Forms
EyeMed Vision Plan
Flexible Spending Forms
 Health Care Forms
Hiring Forms
Leave/Sabbatical Form
  Life & Other Insurance Forms
 Long Term Disability Form
  Non-Faculty Hiring Forms
 Payroll Direct Deposit
  Performance Management Forms
Personnel Action Form (PAF)
 Position Description & Classification Review Forms
 Request for Change of Personal Data Form
 Retirement Forms
  Staffing Forms
 Tax Forms
Tuition Exchange
Tuition Remission
  Union Hiring Forms
 Vacation & Sick Leave Usage Forms

 Forms listed below as Adobe require Adobe Acrobat to view and print.
(click on the words Adobe Acrobat above to download the software).
Health Care Forms
ENROLLMENT FORMS

Indicate your plan choice by writing "Core" or "Advantage" in section 4 on the Anthem enrollment form titled "Type of Coverage/Plan."

Anthem Healthcare Enrollment/Change Form  (pdf)

 
CLAIM FORMS

Anthem Medical Claim
Hyperlink to Adobe Acrobat file of Anthem Medical Claim Form Hyperlink to Microsoft Word file of Anthem Medical Claim form

PRESCRIPTION ORDER FORMS

Anthem NextRx Mail Order (PDF)

Anthem Rx Order Retirees Over 65 Only (PDF)

 

WAIVER FORMS

Employee Health Care Waiver Form (PDF)

Graduate Assistant Health Care Waiver Form (Word)

Retiree Health Care Waiver Form (PDF)

Flexible Spending Forms

Ceridian Direct Deposit Authorization Form (PDF)

Ceridian Health Care Reimbursement Form  (PDF)

Ceridian Dependent Care Reimbursement Form (PDF)

Ceridian Health Care Spending Enrollment Form  (PDF)

Ceridian Dependent Care Spending Enrollment Form  (PDF
Life & Other Insurance Forms
CNA Group
Hyperlink to Adobe Acrobat file of CNA Group Insurance form  Hyperlink to Microsoft Word file of CNA Group Insurance form
UnumProvident Life Insurance Form
UnumProvident Evidence of Insurability Form
UnumProvident Beneficiary Designation Form
UnumProvident Accidental Death & Dismemberment Form
Waiver of Entitlement to Group Term Life Insurance
(in Excess of $50,000)
Long Term Disability
Long Term Disability Form
Position Description & Classification Review Forms
Position Description Form and Guidelines
Hyperlink to Adobe Acrobat file of Position Description Form and Guidelines
Position Description Guidelines only
Position Classification Review Form
Hyperlink to Microsoft Word file of Position Classification Review Form
Position Description Form
Hyperlink to Adobe Acrobat file of Position Description Form Hyperlink to Microsoft Word file of Position Description Form
Union Hiring Forms
Union Recruitment/Hiring Packet
Vacation & Sick Leave Usage Forms
Sick Leave Usage
Hyperlink to Adobe Acrobat file of Sick Leave Usage Form Hyperlink to Microsoft Word file of Sick Leave Usage Form
Vacation Usage
Hyperlink to Adobe Acrobat file of Vacation Usage Form  Hyperlink to Microsoft Word file of Vacation Usage form
Staffing Forms

    Personnel Requisition Form (Non-Faculty Positions) (MS Word)

    Position Description (MS Word)      

    Position Description & Guidelines (pdf)

    Essential Position Functions (MS Word)

    Applicant Rating Worksheet (Excel)

    Interview Evaluation Form (MS Word)

    Employment Recommendation Form (Non-Faculty and Union Positions) (MS Word)

    Employment Application (MS Word)

    Internal Employment Application (MS Word)

    Background Check Release (MS Word)
Continuing Education Forms

    Instructions for Participants

Tuition Remission

    Tuition Remission Application for Employee (MS Word)

    Tuition Remission Application for Child or Spouse (MS Word)
Dental Forms
    Superior Dental Enrollment Form

    Dental Waiver Form (Word)
 Retirement Forms

    Salary Reduction Agreement

    Fidelity Investments 403(b) Beneficiary Designation Form

    TIAA CREF Beneficiary Designation Form
 Adoption Reimbursement Form

    Adoption Reimbursement Form
 EyeMed Vision Plan

    EyeMed Out-of-Network Claim Form
 Tax Forms

    Federal Withholding Certificate (W-4)

    State of Ohio Withholding Certificate (IT-4)
 
 

This site is maintained by the Office of Human Resources.  Direct questions to Stefanie.Rich@notes.udayton.edu.

University of Dayton
St. Mary's Hall Room 118
300 College Park
Dayton, OH 45469-1614