Forms
Instructions: Please download either the fillable MS Word 
format or Adobe Acrobat 
format of a form.
Press Ctrl + F keys to search on this page.
| Employment |
| Employment Application |
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Paper employment applications are no longer available.
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| 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 |
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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.
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| Request for Agency Temporary Personnel |
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Departments complete this form, obtain approvals and contact Human Resources to request agency temporary personnel.
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| W-4 |
| NJ-W4-WT |
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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.
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| Voluntary Self-Identification of Disability Form |
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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.
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| New Position Justification |
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For attachment with Staff Position/Transaction Form (SPTF) and to provide new position justification.
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| Labor Relations |
| Staff Counseling Notice |
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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.
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| Staff Disciplinary Notice |
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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.
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| Outside Activity |
| State of New Jersey Outside Activity |
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Formerly Outside Employment, now resides on the Compliance Website
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| 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 |
| FMLA Self – Submit following three forms. Click Here for directions. |
| Form #1 Request for Leave of Absence Form Click Here
Form #2 US Department of Labor DOL WH-380E Click Here Form #3 Employee Consent Form for Self Click Here (For Chrome/Edge users, right click on PDF icon and save it on your computer first and then open using your local Adobe Reader software.) |
| FMLA Family – Submit following three forms. Click Here for directions.
Form #1 Request for Leave of Absence Form Click Here Form #2 US Department of Labor DOL WH-380F Click Here Form #3 Employee Consent Form for Family Click Here (For Chrome/Edge users, right click on PDF icon and save it on your computer first and then open using your local Adobe Reader software.) |
| FMLA Military Self / Personal Leave / Academic Leave – Submit following one form. Click Here for directions.
Form #1 Request for Leave of Absence Click Here |
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Certification for Serious Injury or Illness of Covered Service Member 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.
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| Certification of Qualifying Exigency for Military Family Leave (Form WH-384) |
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This form is used to support a request for FMLA leave due to a qualifying exigency.
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| Accommodation Request |
| Accommodation Request and Attestation Form |
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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.
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| Medical Exemption |
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Healthcare provider release for Medical Exemption to required immunization and attestation.
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| Performance Appraisal |
| Performance Appraisal Forms |
| Management Appraisal Form |
| Employee Appraisal Form |
| Performance Appraisal Tools |
| Performance Check-In |
| Core Values Behavioral Assessment Worksheet |
| AIDET Competency Assessment Tool |
| Goal Development Worksheet |
| Probationary Assessment Forms |
| Probationary Assessment for Union Represented Staff |
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Supervisors complete this form approximately three weeks prior to the last day of the probationary period for newly hired,
transferred or promoted staff.
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| Introductory Period Assessment for Confidential Employees |
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This form is used to assess confidential staff employees upon completion of the Introductory Period.
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| Competency Assessment Form |
| This form is to be used for clinical and ancillary staff who require competency assessment annually. |
| New Electronic Staff Transaction |
| Electronic Staff Position/Transaction Form Staff Position/Transaction Form Ellucian Workflow |
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To initiate position request for new and replacement positions only.
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| Staff Transaction |
| Staff Position/Transaction Form |
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To initiate position requests, i.e., acting appointments, reclassifications, work hours adjustment and WFM changes.
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| Background Screening |
| Criminal Background Check Request |
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To request a criminal background check on selected candidates.
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| Disclosure and Authorization |
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To initiate background and criminal checks for employment candidates.
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| Regular and Volunteer Staff |
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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.
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| UH Paid & Volunteer Faculty Personal Data (Being Revised) |
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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.
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| Background Check for Nursing Positions |
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To initiate background check for nursing positions.
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| Volunteer |
| Volunteer Information Sheet |
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To be completed by applicants requesting volunteer staff assignments.
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| Volunteer Waiver Form (Being Revised) |
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To be signed by volunteer applicants and department supervisors acknowledging waiver of coverage under the Workers Compensation Act.
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| Internship Program |
| Internship Program Packet |
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To be completed by applicants requesting internship assignments.
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| Health Care Professional Responsibility & Reporting Enhancement Act |
| HCPRREA Form |
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Use to report HCPRREA events to the Division of Consumer Affairs (DCA) and to respond to HCPRREA requests from outside entities.
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| Benefits |
| ABP Retirement Application |
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ABP Retirement Application form
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| Change of Address |
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Please visit the State of New Jersey website to access your MBOS or Benefitsolver account to update your address.
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| Designation of Beneficiary (PERS & PFRS Members) |
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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)
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| Designation of Beneficiary (ABP & DCRP Members) |
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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.
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| Horizon MyWay FSA: Enrollment Form | Change in Status Form |
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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.
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| Medical and Dental Enrollments/Changes |
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Enrollments and changes to medical and dental plans with the State Health Benefits Program (SHBP) are done on line
through Benefitsolver. Please go to nj.gov/treasury/pensions/
then to State Employees: Access Benefitsolver to register or login.
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| Member Benefits Online System (MBOS) State of NJ – Department of the Treasury – NJDPB | PERS |
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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.
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| Salary Reduction/Allocation Agreement |
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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.
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| Staff Leave Donation Request Form |
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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.
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| Staff Leave Donation Program Donation Sheet |
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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).
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| Staff Leave Donation Program Patient Authorization Form |
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Patient Authorization and Physician/Health Care Provider Certification form for Staff Leave
Donation Program application.
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| State Health Benefits Program State of NJ – Department of the Treasury – NJDPB | Summary of Benefits & Coverage for Active State Employees |
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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.
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Education Assistance Program Application
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.
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| Withdrawal Applications (PERS- PFRS) State of NJ – Department of the Treasury – NJDPB | PERS |
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For additional information regarding withdrawals and application links please visit the Division
of Pensions and Benefits above.
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| HDHP Health Savings Account (HSA) Contribution Form |
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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.
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| Human Resources Information Systems |
| Letter of Employment |
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Download instructions to generate a Letter of Employment.
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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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