Wichita State University -- Benefits & Medical Leave
Forms used for:
| Forms by Name | Link to Instructions | Purpose of this Form | Version |
| FMLA Request | To apply for the Family & Medical Leave benefit. Two-pages -- to be completed & signed by the employee. | ||
| FMLA Certification of Health Care Provider | For the physician to provide information concerning the patient to determine FMLA eligibility. This 5 page form also includes the Return to Work Authorization form necessary to return to work after a qualifying event. To be fully completed by the health care provider to reflect all pertinent information regarding the employee's need to be absent from work and to be signed by the health care provider and the employee. | ||
| FMLA Certification for Serious Injury or Illness of Covered Service Member | To be completed by a Department of Defense health care provider. | Word |
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| FMLA Certification of Qualifying Exigency for Military | To be completed by employee. | Word |
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| FMLA Timekeeping Verification | Used to track FMLA certified absences for one diagnosis. Employee may use this form to record the hours absent for each FMLA absence as the absence occurs. | ||
| Flexible Spending Claim Form (ASI) |
Included |
To claim reimbursement of dependent care and/or unreimbursed medical expenses. | |
| Shared Leave Request | To apply for shared leave. | ||
| Shared Leave Confidentiality Waiver | Required in order for HR to solicit donation of leave hours from eligible employees. | ||
| Shared Leave Donation of Time | For employees to donate vacation and/or sick leave to employees approved for shared leave. | ||
| Shared Leave Certification of Physician | Required for an employee to apply for shared leave -- a 5 page form (the last page is the Return to Work Authorization). | ||
| Tuition Assistance | The University has authority under state law to pay tuition and other education expenses for the education or training of eligible University employees when such education or training has been determined to be of value to the state and the University. |
Word |
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| Voluntary Investment Agreement Plan | This Investment Agreement is entered into between the undersigned employee of the Wichita State University in order for salary deferral contributions to be made to the Kansas Board of Regents Voluntary Retirement Plan under Internal Revenue Code (IRC) Section 403(b) and K.S.A. § 74-4925b. | ||
| Workers Compensation Employee Accident or Illness Report | A 2 page form for employee or supervisor to complete in the event of a work-related accident or illness and sent to Employee Relations at Campus Box #115 within 3 days of the incident. | ||
| Workers Compensation Mileage Report | For travel to workers comp related appointments. |
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