Benefits & Medical Leave
Forms used for:
| Forms by Name | Link to Instructions | Purpose of this Form | Version |
| FMLA Request | To be eligible for the Family & Medical Leave benefit, employees must have 12 months of University/State service and to have worked 1,250 hours in the immediate previous 12 months. The two pages of this form are 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. | |
| Investment Agreement -- Mandatory Retirement Plan | This form is required in order for salary deferral contributions to be made to the Kansas Board of Regents Mandatory Retirement Plan under Internal Revenue Code Section 403(b) and K.S.A. 74-4925. | ||
| Investment Agreement -- Voluntary Pre-Tax | This form is required 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. | ||
| Investment Agreement -- Voluntary Roth After-Tax | Roth Option Announced Jan. 2011 | This form is required 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 | |
| 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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| 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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