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HUMAN RESOURCES

Benefits & Medical Leave

Forms used for:

 

 Forms by Name  Link to Instructions  Purpose of this Form  Version
 FMLA Request

How to Apply

 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.

Word 
*PDF

 FMLA Certification of Health Care Provider

 FMLA Guidelines

 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.

 Word
*PDF

 FMLA Certification for Serious Injury or Illness of Covered Service Member    To be completed by a Department of Defense health care provider. Word
*PDF
 FMLA Certification of Qualifying Exigency for Military    To be completed by employee. Word
*PDF
 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.

Word
*PDF

 Flexible Spending Claim Form (ASI)

Included 

 To claim reimbursement of dependent care and/or unreimbursed medical expenses.

Word
*PDF

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. *PDF
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. *PDF
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 *PDF
 Shared Leave Request

Guidelines

 To apply for shared leave.

Word
*PDF

 Shared Leave Confidentiality Waiver    Required in order for HR to solicit donation of leave hours from eligible employees.

Word
*PDF

 Shared Leave Donation of Time    For employees to donate vacation and/or sick leave to employees approved for shared leave.

Word
*PDF

 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).

Word
*PDF

 Tuition Assistance

Guidelines

 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
*PDF

 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.

Word
*PDF

 Workers Compensation Mileage Report    For travel to workers comp related appointments.

Word
*PDF

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