Forms

Payroll Forms

General Forms

• Authorization of Direct Deposit (PDF)
• Reversal of Direct Deposit (PDF)
• Election to Annualize Recurring Part-Year Compensation (PDF) 
• Federal W-4 (2019) (PDF)
• Missouri W-4 (2019) (PDF)
• City of St. Louis Tax Withholding Form (PDF)
• Gift, Prize, or Award Form (PDF)
• Form I9: Employment Eligibility Verification (External Website)
• Personal Information Form – Employee (PDF)
• Personal Information Form – Non-Employee (PDF)

Telecommuting Forms

• Telecommuting Agreement and Assignment (PDF)
• Telecommuting Confidentiality & Security Policy Acknowledgement (PDF)

---

Benefits Forms

General Forms

• Medicare Status Form (PDF)

Healthcare Forms

• Enrollment Change Form (PDF)
• Enrollment Change Form – Union Power Plant Employees (PDF)
• Postdoctoral Appointees Change Form (PDF)
• Clinical Fellows Change Form (PDF)
• Retiree Enrollment Form (PDF)
• Electronic Funds Transfer Form (PDF)
• Dependent Verification Affidavit Form (PDF)
• Dependent Verification Affidavit Form – Postdocs/Union Power Plant Employees (PDF)
• Domestic Partner Declaration Form (PDF)
• UnitedHealthcare Claim Form (PDF)
• UnitedHealthcare International Claim Form (PDF)
• Advantica Dental Claim Form (PDF)
• Express Scripts Claim Form (PDF)
  To be completed only if you need to submit a claim for reimbursement
• Express Scripts Mail-Order Form (PDF)
• Spouse/Domestic Partner Premium Surcharge Change Form (PDF)
• VSP Claim Form (PDF)

Flex Spending

• ConnectYourCare Medical Expense Reimbursement Form (PDF)
  Also known as the “Pay Me Back” form for Medical Expense
• ConnectYourCare Dependent Child Care Benefits Reimbursement Form (PDF)
  Also known as the “Pay Me Back” form for Child Care

Life Insurance

• Life Insurance Enrollment/Change Form (PDF)
• Life Insurance Domestic Partner Declaration Form (PDF)
• Life Insurance Portability Rate Form (PDF)

Long Term Disability

• Long Term Disability Buy-Up Enrollment Form (PDF)
• Evidence of Insurability Form (PDF)

Retirement

• RA/GRA/SRA Comparison Chart (PDF)
• W-4P Form (PDF)
• Tenured Faculty Phased Retirement Program Application Form (PDF)
• Tenured Faculty Basic Phased Retirement Program Agreement Form (PDF)
• Tenured Faculty Enhanced Phased Retirement Program Agreement Form (PDF)
• Clinician Track Faculty Phased Retirement Program Application Form (PDF)
• Clinician Track Faculty Basic Phased Retirement Program Agreement Form (PDF)
• Clinician Track Faculty Enhanced Phased Retirement Program Agreement Form (PDF)

RMSA

• RMSA Cancellation Form (PDF)
  Complete Sections A,H,and I to cancel RMSA
• RMSA Claims Activation Form (PDF)

Tuition Assistance

• Undergraduate Employee Tuition Assistance Request Form (PDF)
• Graduate Employee Tuition Assistance Request Form – Job Related (PDF)
• Graduate Employee Tuition Assistance Request Form – Non-Job Related (PDF)
• Dependent Child Tuition Assistance Request Form (PDF)
  • Dependent Child Tuition Assistance Authorization to Release Information Form (PDF)
  • Ex-Spouse Dependent Tuition Affidavit Form (PDF)
  • Dependent Eligibility Affidavit Form (PDF)
• Spouse Tuition Assistance Request Form (PDF)
• Domestic Partner Tuition Assistance Request Form (PDF)
• Employee Taxation on Non-Job Related Tuition Form (PDF)
• Postdoctoral Appointees Tuition Assistance Form (PDF)
• Nursing Tuition Assistance Request Form (PDF)

---

FMLA Forms

• Family and Medical Leave Application Form (PDF)
• Certification of the Health Care Provider for Employee Leave Form (PDF)
• Certification of the Health Care Provider for Family Member Leave Form (PDF)
• Certification for Serious Injury or Illness of Current Service Member Form (PDF)
• Notice of Eligibility and Rights and Responsibilities Form (DOC)
• Certification of Qualifying Exigency for Military Family Leave Form (PDF)
• Certification for Serious Injury or Illness of a Veteran Form (PDF)
• FMLA Poster (PDF)
• FMLA Designation Notice
• Return to Work Form (PDF)

Other Leaves

• General Medical Leave Application (PDF)
• General Medical Leave Letter (PDF)
• Personal Leave Application (PDF)
• Personal Leave Letter (PDF)

---

Compensation Forms

General

• Bi-Weekly/Nonexempt Time Sheet (XLS)
• Employee Income Verification Form (PDF)

Independent Contractor Status

• Determining Employee/Independent Contractor Status Questionnaire (PDF)

Management Tools

• Bonus Authorization Form (PDF)
• Job Description Template (DOC)

---

Performance Management Forms

Employee Evaluation (New Condensed Format)

• Administrative/Support Evaluation Form – Condensed (RTF)
• Supervisory/Professional Evaluation Form – Condensed (RTF)

Employee Evaluation (Original Format)

• Administrative/Support Evaluation Form (DOC)
• Administrative Self Evaluation Form (RTF)
• Supervisory/Professional Evaluation Form (DOC)
• Supervisory Self Evaluation Form (RTF)

---

Career and Professional Development

• Competencies for Success at Washington University
• Individual Development Plan – Guidelines and Form (PDF)
• Career Development

---

HRMS Forms

General

• Deans, Department Heads, and Directors Label Request Form (PDF)
• HRMS Security Authorization Form (External Website)
• Miscellaneous Address Label Request Form (PDF)
• HRMS How-To Guide
• HRMS Action Reason Guide

---

Other Forms

• Public Service Loan Forgiveness Form (PDF)