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NC Department of Health and Human Services
Division of Human Resources
 
 
 
NC DHHS HR

Forms

General

Academic Assistance external link (OSHR)
Federal IRS Forms external link (IRS)
Federal Tax Withholding W4 (PDF, 224KB)
Governor’s Awards for Excellence (GAE) Nomination Form (DOC, 753KB)
I-9 Employment Eligibility Verification external link (USCIS)
Immigration and Naturalization Form external link (USCIS)
Job Application external link (OSHR)
NC Flex Forms (PDF, 98KB)
New Employee Orientation Checklist (PDF, 41KB)
Separation Forms

2013 NC-4 Withholding Allowance Certificate external link (DOR)
2014 NC-4 EZ and NC-4 Employee's Withholding Allowance Certificate


State Retirement Beneficiary Designation Form (PDF, 974KB)
State Health Plan Important Forms external link (State Health Plan)
Excels Values Definitions, Roles and Key Actions (DOC, 236KB)
New Health Insurance Marketplace Coverage Options and Your Health Coverage notice (PDF, 2408KB)

Work Performance Plan Forms (for FY 2014-2015)

Forms for HR Staff

Benefits

Certificate of Health Care Provider for Employee’s Serious Health Condition (Form WH-380-E) external link (US DOL)
Certificate of Health Care Provider for Family Member’s Serious Health Condition (Form WH-380-F) external link (US DOL)
Certificate of Qualifying Exigency for Military Family Leave external link (US DOL)
Certification for Serious Injury or Illness of Covered Service member for Military Family Leave external link (US DOL)
Family Medical Leave Act / Family Illness Leave Request Form (PDF, 201KB)
Family Medical Leave Provisional Designation Letter (DOC, 31KB)
Family Medical / Family Illness Leave Denial Letter (PDF, 30KB)
Voluntary Shared Leave Application (PDF, 157KB)
Voluntary Shared Leave Donation (DOC, 53KB)

Classification and Compensation

319 Employee Relationship Questionnaire (PDF, 908KB)
ADA Checklist (PDF, 115KB)
Agency Check Request (DOC, 48KB)
Analyst Notes (General) (PDF, 501KB)
Analyst Notes (Career Banding) (DOC, 96.9KB)
Analyst Notes (OSSOG) (PDF, 311KB)
Contract Approval (PDF, 111KB)
Career Banding Forms
Career Banding Pay Dispute Process (PDF, 71KB)
Dual Employment external link (Instructions PDF, 84KB)
FLA Test Executive (PDF, 367KB)
FLSA Test Administrative (PDF, 358KB)
FLSA Test Professional (PDF, 259KB)
FLSA Test Creative Professional (PDF, 359KB)
FLSA Test Computer Related (PDF, 362KB)
Freeze Release (Divisions)(DOC, 162KB)
Freeze Release (Facilities) (DOC, 149KB)
In-Range Equity (DOC, 47KB)
In-Range Job Growth (DOC, 47KB)
In-Range Labor Market (DOC, 43KB)
Job Description external link (DOC, 79.5KB)
Mentor Pay Authorization (DOC, 59KB)
Nurse Sign On Bonus PAF (PDF, 68KB)
Nurse Weekend Option Day Memorandum (DOC, 41KB)
Nurse Weekend Option Night Memorandum (DOC, 41KB)
Overtime/On Call/Call Back Agreement (PDF, 89KB)
Position Spreadsheet (XLS, 54KB)
Program Evaluation Guide (PDF, 478KB)
Request to Add Position/Class to On-Call List (PDF, 196KB)
Retention Adjustment Worksheet (PDF, 50KB)
Retired Temporary Employees Agreement (PDF, 246KB)
Salary Decision Worksheet (Career Banding) (DOC, 64KB)
Salary Equity Analysis Worksheet (XLS, 41KB)
Salary Overpayment Collection (Instructions DOC 29k) (Form DOC 44k)
Salary Exception Worksheet (PDF, 53KB)
Secondary Employment Form (DOC, 49KB)
Sleep Policy Agreement (PDF, 86KB)
Unofficial Trainee Worksheet (PDF, 61KB)
Work Against Worksheet (PDF, 359KB)

Employee Relations

DHHS EEO Plan (2014) (PDF, 2923KB)
EEO Informal Intake Complaint Form (PDF, 124KB)
EEO Informal Intake Complaint Instructions (PDF, 12KB)
Employee Grievance Filing Form (PDF, 18KB)
Grievance Management Response Form (PDF, 14KB)
Grievance Step 2 Appeal Notice (PDF, 39KB)
Proposed Dismissals, Demotions and Disciplinary Suspensions Form (PDF, 175KB)
Program Evaluation Form (PDF, 364KB)
Statement of Backpay (PDF, 261KB)

Learning and Development

Application For Academic Assistance external link (OSHR)
Academic Assistance Annual Report (PDF, 44KB)
Continuing Education Units Application (PDF, 148KB)
Continuing Education Units Instructor Credentials Form (PDF, 141KB)
Continuing Education Units Planning Worksheet (PDF, 109KB)
Continuing Education Units Review (PDF, 86KB)
Conference Authorization (PDF, 442KB)
LeadershipDHHS Program (DOC, 476KB)
OSHR Professional Skills Course Registration external link (OSHR)
EEOI Registration (PDF, 18KB)
Extended Academic Leave Request (PDF, 44KB)
Training Requirements Acknowledgement (PDF, 17KB)

Recruitment

Freeze Guidelines (DOC, 141KB)
Job Posting Form (PDF, 105KB)
GS 126 RIF PLAN Template (DOC, 64KB)
GS 126 RIF Worksheet (XLS, 17KB)
GS 115C RIF PLAN Template (DOC, 44KB)
GS 115C RIF Worksheet (XLS, 17KB)
Reference Check (PDF, 106KB)
Release Form (PDF, 111KB)

Safety

Safety and Health Director's Accident/Injury Investigation Form (DOC, 186KB)
Confined Space Survey (DOC, 320KB)
Confined Space Permit (DOC, 95KB)
Ergonomic Assessment (DOC, 134KB)
Ergonomic Assessment (Supervisor)(DOC, 910KB)
Fire Equipment Inspection (DOC, 131KB)
Indoor Air Quality Inspection (PDF, 292KB)
Medical Provider Opinion (DOC, 47KB)
Medical Surveillance Questionnaire (DOC, 175KB)
OSHA Log (XLS, 646KB)
Quarterly Statistical Report Form (XLS, 293KB)
Safety Inspection Checklist (DOC, 112KB)
Safety Training Evaluation (DOC, 59.5KB)
Safety Training Participation (DOC, 42KB)

Additional Programs (Criminal Records, Drug Testing, Workplace Violence)

Applicant Consent and Acknowledgement Form (DOC, 37.5KB)
Consent and Acknowledgement for CDL (PDF, 121KB)
Consent and Acknowledgement Form for Random and Reasonable Cause (PDF, 91KB)
Criminal Justice Drug Test Applicant Consent Form (PDF, 245KB)
Criminal Record Check Consent (PDF, 83KB)
Criminal Record Check Letter (PDF, 137KB)
Criminal Record Check Request (PDF, 270KB)
Criminal Record Check Transmittal (PDF, 125KB)
Direct Care / Critical Care Request (PDF, 253KB)
Direct Care List
Critical Care List
Statistical Report (PDF, 271KB)

Workers' Compensation

CorVel Medical Authorization and Prescription Form (DOC, 90KB)
Death Claim Notice (PDF, 244KB)
DHHS Witness Statement (DOC, 40KB)
Employee Injury Report (DOC, 71KB)
Supervisor Investigation Form (DOC, 54KB)
Leave Option Form (DOC, 38KB)
Return to Work with Restricted Duties (DOC, 44KB)
Separation for Unavailability--WC Conference Letter
Separation for Unavailability--WC Separation Letter--Return to Work
Separation for Unavailability--WC Separation Letter--No Return to Work
Supplemental Leave Schedule (DOC, 26KB)
Settlement Approval Request Form (DOC, 60KB)
Statement of Charges for Travel external link (NCIC 25T)
Statement of Days Worked and Earnings of Injured Employee external link (NCIC 22)

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