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Forms

Instructions: Please download either the fillable MS Word   format or Adobe Acrobat   format of a form.

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 Employment 
Employment Application                  https://jobs-us.technomedia.com/uhospital/
Paper employment applications are no longer available.
Click on the link to apply for employment or to make an internal bid.
Employee’s Certificate of Non-Residence in New Jersey

To stop the withholding of New Jersey income tax, complete an Employee’s Certificate of Non-Residence in New Jersey

– Pennsylvania residents only.

I-9
All U.S. employers are responsible for completion and retention of I-9 for each individual they hire for employment in the United States.
This includes citizens and non-citizens.
Request for Agency Temporary Personnel
Departments complete this form, obtain approvals and contact Human Resources to request agency temporary personnel.
W-4
NJ-W4-WT
Complete these forms so that your employer can withhold the correct federal and state income tax from your pay.
Because your tax situation may change, you may want to recalculate your withholding each year.
Voluntary Self-Identification of Disability Form
Completing this form is voluntary, but we hope that you will choose to fill it out, why?
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.
To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability.
New Position Justification
For attachment with Staff Position/Transaction Form (SPTF) and to provide new position justification.
 Labor Relations 
Staff Counseling Notice
To document a counseling session between a staff member and his/her supervisor
regarding issues such as performance, attendance, employee conduct or any other failure to follow policies/procedures.
This is not to be used for issuing discipline.
Staff Disciplinary Notice
To issue a formal disciplinary action, i.e., written warning; suspension without pay; written warning in lieu of suspension without pay; or termination.
Prior to the issuance of a disciplinary action, Labor Relations must be consulted.
 Outside Activity 
State of New Jersey Outside Activity
Formerly Outside Employment, now resides on the Compliance Website
 Out of Title 
Out-of-Title/Payroll Request for Check for Staff Only
To obtain payment for out-of-title work.
Request/Approval for Out-of-Title Work for Staff Only
To obtain approval for temporary, secondary employment within University Hospital.
 Leave of Absence 
Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave (Form WH-385)
This form is used to obtain medical certification from the “covered service member’s” health care provider.
It is completed by the employee and the health care provider.
Certification of Health Care Provider for Employee’s Serious Health Condition (Form WH-380-E)
This form is used to obtain medical certification to support a request for FMLA leave for the employee’s own serious health condition.
Certification of Health Care Provider for Family Member’s Serious Health Condition (Form WH-380-F)
This form is used to obtain medical certification from the Family’s Member health care provider.
Certification of Qualifying Exigency for Military Family Leave (Form WH-384)
This form is used to support a request for FMLA leave due to a qualifying exigency.
Request for Leave of Absence
For employees to initiate the Leave of Absence process, the form must be completed and submitted along with appropriate supporting documentation.
 Accommodation Request 
Accommodation Request and Attestation Form
Please complete this form to request an accommodation based on religion or because of a disability.
If you are requesting an accommodation due to a disability you must provide medical or other appropriate documentation.
Medical Exemption
Healthcare provider release for Medical Exemption to required immunization and attestation.
 Performance Appraisal
Performance Appraisal Forms
Management Appraisal Form
Employee Appraisal Form
Performance Appraisal Tools
Performance Check-In
Core Values Behavioral Assessment Worksheet
Goal Development Worksheet
Probationary Assessment Forms
Probationary Assessment for Union Represented Staff
Supervisors complete this form approximately three weeks prior to the last day of the probationary period for newly hired, transferred or promoted staff.
Introductory Period Assessment for Confidential Employees
This form is used to assess confidential staff employees upon completion of the Introductory Period.
 New Electronic Staff Transaction 
Electronic Staff Position/Transaction Form
Staff Position/Transaction Form Ellucian Workflow

To initiate position request for new and replacement positions only.
 Staff Transaction 
Staff Position/Transaction Form

To initiate position requests, i.e., acting appointments, reclassifications, work hours adjustment and WFM changes.
 Background Screening 
Criminal Background Check Request
To request a criminal background check on selected candidates.
Disclosure and Authorization
To initiate background and criminal checks for employment candidates.
Regular and Volunteer Staff
To initiate the mandatory background check for a selected candidate before employment is finalized.
Also, to obtain a background check for volunteer applicants before volunteer service begins.
UH Paid & Volunteer Faculty Personal Data Being Revised
To initiate the mandatory background check for a selected faculty candidate before employment is finalized.
Also use this form to obtain a background check for volunteer faculty applicants.
Background Check for Nursing Positions
To initiate background check for nursing positions.
 Volunteer 
Volunteer Information Sheet
To be completed by applicants requesting volunteer staff assignments.
Volunteer Waiver Form Being Revised
To be signed by volunteer applicants and department supervisors acknowledging waiver of coverage under the Workers Compensation Act.
 Internship Program 
Internship Program Packet
To be completed by applicants requesting internship assignments.
 Health Care Professional Responsibility & Reporting Enhancement Act 
HCPRREA Form
Use to report HCPRREA events to the Division of Consumer Affairs (DCA) and to respond to HCPRREA requests from outside entities.
 Benefits 
ABP Retirement Application
ABP Retirement Application form
Certification of Documents
The notarized Certification of Documents form is submitted with the required documentation when applying for a
Hardship Withdrawal from your ABP 403(b) or ACTS 403(b) plans.
Change of Address
Please visit the State of New Jersey website to access your MBOS or Benefitsolver account to update your address.
Designation of Beneficiary (PERS & PFRS Members)
As of February 1, 2013 the Division of Pensions and Benefits will no longer accept the Designation of Beneficiary form.
Changes to the beneficiary information must be done on line through the Member Benefits Online System (MBOS)
Designation of Beneficiary (ABP & DCRP Members)
The Division of Pensions and Benefits requires this form to change the beneficiary information listed for your group life insurance.
To change the beneficiary information listed on your personal pension accounts contact the investment provider directly.
Please retain a copy for your own records and forward the form to the address listed on the form.
Horizon MyWay FSA:
Enrollment Form | Change in Status Form

Eligible employees who wish to enroll in the Tax$ave Program Unreimbursed Medical (UMSA) or Dependent Care (DCSA) must complete this form.
Enrollment is only in October during Open Enrollment; coverage is effective January 1st of the following year or within 30 days of your date of hire.
Please mail or fax the form directly to Horizon MyWay.
Medical and Dental Enrollments/Changes
Enrollments and changes to medical and dental plans with the State Health Benefits Program (SHBP) are done on line through Benefitsolver.
then to State Employees: Access Benefitsolver to register or login.
Member Benefits Online System (MBOS)
State of NJ – Department of the Treasury – NJDPB | PERS
New Jersey Division of Pensions and Benefits link to register for the Members Benefits Online System (MBOS) for PERS and PFRS members.
Online applications available; pension loans, purchase service credit, change of beneficiary, retirement estimates, pension withdrawal forms and health benefits account information.
Salary Reduction/Allocation Agreement
The Salary Reduction/Allocation Agreement form is used when making changes to the Alternate Benefit Program (ABP) Investment Provider election.
This form along with a copy of the new Investment Provider enrollment application is submitted the Benefits Services Office.
Staff Leave Donation Request Form
This form needs to be completed when staff members are requesting approval to be a
recipient of donated time from coworkers (staff) for a life-threatening or catastrophic
illness for themselves or immediate family members.
Staff Leave Donation Program Donation Sheet
This form needs to be completed by staff members requesting approval to be a donor of donated time for a life-threatening or catastrophic illness of coworkers (staff).
Staff Leave Donation Program Patient Authorization Form
Patient Authorization and Physician/Health Care Provider Certification form for Staff Leave Donation Program application.
State Health Benefits Program
State of NJ – Department of the Treasury – NJDPB | Summary of Benefits & Coverage for Active State Employees
This hyperlink to the Division of Pensions and Benefits will take you to Quick Links for
Health Benefits Members website which includes Members Handbooks, Benefit Summaries, applications and more.
Education Assistance Program Application (formerly Tuition Assistance Program) 

The Education Assistance Program application needs to be signed by employee’s supervisor prior to the start of the program.
The application along with the documentation must be received in the HR Benefits Services Office within 90 business days after the completion of the program.
Withdrawal Applications (PERS- PFRS)
State of NJ – Department of the Treasury – NJDPB | PERS
For additional information regarding withdrawals and application links please visit the Division of Pensions and Benefits above.
HDHP Health Savings Account (HSA) Contribution Form 

An employee who has elected a High Deductible Health Plan (HDHP)
and would like to enroll in the Health Savings Account (HAS) should complete this form
and send it along with the HDHP application to your Campus Benefits Services Representative.
Note: If you are already enrolled in the Flexible Saving Account you are not eligible for the Health Savings Account.
 Human Resources Information Systems  
Letter of Employment
Use this form to request a verification letter of employment.
Download the PDF version and follow the instructions.
Report Library Automated System (RLAS) Information Request

Use this form to request Banner employee data from Human Resources.
Request for data must be relevant to your business needs.
Download the PDF version and follow the instructions.
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