DHHS Division of Human Resources
Department of Health and Human Services
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Forms


With these Adobe PDF forms you can complete the input fields and save the file to your computer.

General Employee Forms
Academic Assistance Immigration and Naturalization Form
BEACON Role Change Request Job Application PD-107
Critical Care List
Direct Care List
NC Flex Forms
Federal IRS Form State Tax Withholding NC-4
Federal Tax Withholding W4 State Retirement Beneficiary Designation Form
Freeze Guidelines State Health Plan Important Forms
Freeze Release Form (Divisions) Salary Overpayment Collection
[password protected form]
Freeze Release Form (Facilities) Separations
I-9 Employment Eligibility Vertification

Work Plan Form (Non-Banded)

Work Plan Form (Banded)


Classification Compensaton
319 Employee Relationship Questionnaire Job Description (PD-OSS93)
ADA Checklist Job Description (PD102r-92)
Agency Check Request
Nurse (Baylor) 60 Hour Contract
Analyst Notes (General) Nurse (Baylor) 72 Hour Contract
Analyst Notes (Career Banding)
Nurse Sign On Bonus PAF
Analyst Notes (OSSOG)
 Overtime/On Call/Call Back Agreement New
Contract Approval Form
Career Banding Pay Dispute Process Form Program Evaluation Guide
Dual Employment CP - 30
Request to Add Position/Class to On-Call List
FLA Test Executive
Retention Adjustment Worksheet
FLSA Test Administrative  
Retired Temporary Employees Agreement
FLSA Test Professional
Salary Decision Worksheet
Salary Equity Analysis Worksheet
FLSA Test Creative Professional
Salary Qualifications Worksheet
FLSA Test Computer Related
Salary Exception Worksheet
In-Range Equity
Secondary Employment Form
In-Range Job Growth Form Sleep Policy Agreement New
In-Range Labor Market Form
Job Description (Career Banded)
Unofficial Trainee Worksheet
Job Description (Interns) New Work Against Worksheet
Employee and Management Development
Application For Academic Assistance OSP Professional Skills Course Registration
Academic Assistance Annual Report EEOI Registration
Continuing Education Units Application Extended Academic Leave Request
Continuing Education Units Instructor Credentials Form Managing Effective Performance
Continuing Education Units Planning Worksheet Staff Development Report
Continuing Education Units Review

Staff Development Report
w/instructions

Conference Authorization

Training Requirements Acknowledgement



Employee Relations
Employee Disciplinary Action Routing Form Proposed Dismissals, Demotions and Disciplinary Suspensions Form
Employee Grievance Filing Form Program Evaluation Form
Performance Rating Dispute Process Complaint Filing Form Statement of Backpay


Recruitment
Applicant Selection Codes

GS 126 RIF PLAN Template
GS 126 RIF Worksheet

GS 115C RIF PLAN Template
GS 115C RIF Worksheet

Applicant Selection Log (PDF)
Applicant Selection Log (Word)
Reference Check (PDF)
Reference Check (Word)
Job Posting Form (PDF)
Job Posting Form (Word)
Release Form (Word)
Release Form (PDF)
Consent to Disclose Information For Reference Checks


Safety
Benefits
Applicant Consent and Acknowledgement Form Certificate of Healthcare Provider
Consent and Acknowledgement for CDL Certificate of Qualifying Exigency for Military Family Leave
Consent and Acknowledgement Form for Random and Reasonable Cause Certificate of Qualifying Exigency for Military Family Leave
Criminal Record Check Consent Certification for Serious Injury or Illness of Covered Service member for Military Family Leave
Criminal Record Check Letter Death Claim Notice
Criminal Record Check Request Family Medical Leave Act / Family Illness Leave Request Form
Criminal Record Check Transmittal
Direct Care / Critical Care Request Voluntary Shared Leave Application
Drug Test Program Release of Information Form Voluntary Shared Leave Donation
State Employee Incentive Bonus Program Routing Form  
State Employee Incentive Bonus Program Employee  Suggestion Form
Statistical Report
Worker's Compensation
CorVel Medical Authorization and Prescription Form Return to Work with Restricted Duties
CorVel First Fill Prescription Letter
DHHS Witness Statement Settlement Approval Request Form

Employee Injury Report
Supervisor Investigation Form

Statement of Charges for Travel (NCIC 25T)
Leave Option Form Statement of Days Worked and Earnings of Injured Employee (NCIC 22)

Obsolete Form(s)

Last modified: November 5, 2009