Human Resources Forms Library

Forms Home  | Benefits Forms  | Compensation Forms  | Recruitment and Staffing Forms  | Staff and Labor Relations Forms  | Quality of Worklife Forms   | Click here to access Finance / Payroll forms (e.g., Direct Deposit, W-4)

The Division of Human Resources offers most of its forms online in electronic format. Our forms are offered in a variety of formats, depending on the form, and can be printed and filled out. Click a category to the left to begin browsing the Forms Library.

The majority of forms in the Forms Library are offered in Adobe Acrobat (PDF) format. If you need to download the free Adobe Acrobat Reader, please visit the Adobe web site by clicking the graphic below. Please note: If you need to download and install the Adobe Acrobat Reader on a University supported computer, it is advisable to contact your Local Support Provider (LSP) prior to doing so.

A complete list of all Division of Human Resources forms is available below. You can also access department-specific forms pages using the navigation bar on the lefthand side of the screen, or the menu above.

Benefits Forms

	Affidavit of Common Law Marriage		Acrobat PDF		Use to certify an opposite- sex common law spouse for benefits eligibility

 

	MetLife Dental Claim Form		Acrobat PDF

 

	Affidavit of Domestic Partnership		Acrobat PDF		Use to certify an same- sex common law spouse for benefits eligibility

 

	Termination of Domestic Partnership		Acrobat PDF		Use to dissolve same- sex common domestic partnership

 

	Group Life Insurance Beneficiary Designation - Aetna		Acrobat PDF		Use this form to newly elect or update your life insurance beneficiary.

 

	AmeriHealth/UPHS Point of Service Self-Referred Claim Form		Acrobat PDF
	Keystone/UPHS Point of Service Self-Referred Claim Form		Acrobat PDF
	PennCare Major Medical Claim Form		Acrobat PDF
	Plan 100 Major Medical Claim Form		Acrobat PDF

 

	How to File Claims for Services with Penn Behavioral Health		Acrobat PDF
	Penn Behavioral Health Claim Form		Acrobat PDF

 

	Visiting Scholar Health Coverage Worksheet – FY09		Acrobat PDF
	Visiting Scholar Health Premiums - FY09		Acrobat PDF

 

	Caremark Prescription Drug Claim Form		Acrobat PDF
	Caremark Prescription Drug Mail Order Form		Acrobat PDF

 

	Health Care Pre-Tax Expense Account: Request for Reimbursement		Acrobat PDF
	Dependent Care Pre-Tax Expense Account: Request for Reimbursement		Acrobat PDF
	Pre-Tax Expense Account Direct Deposit Authorization		Acrobat PDF		Use this form to have your Pre-Tax Expense Account reimbursements directly deposited into a checking or savings account

 

	Physician's Certification		Acrobat PDF
	Short Term Disability & Family Medical Leave Request Form		Acrobat PDF
	Intermittent Leave Tracking Form		Acrobat PDF
	Work Sheet For Calculating Monthly Sick Balances		Acrobat PDF
	Family and Medical Leave (FMLA) Provisional Letter #1 - Policy 631		Word 97/2000		Staff member has been out sick for more than 3 consecutive days and has not notified you.
	Family and Medical Leave (FMLA) Provisional Letter #2 - Policy 631		Word 97/2000		Staff member has notified you s/he will be out for possible FML qualifying event for his/her own serious medical condition.
	Family and Medical Leave (FMLA) Provisional Letter #3 - Policy 631		Word 97/2000		Staff member has notified you s/he will be out for possible FML qualifying event to care for family member with a serious medical condition.
	Family and Medical Leave (FMLA) Provisional Letter #4 - Policy 631		Word 97/2000		Staff member has notified your s/he will be out for possible FML qualifying event for birth/placement of a child for adoption.

 

	Prior Service Credit:  Employee Certification		Acrobat PDF		Use to waive the 1-year waiting period under the TDR
	Prior Service Credit:  Sample Letter from Prior Employer		Acrobat PDF		Use to waive the 1-year waiting period under the TDR
	Calculating Your Maximum Contribution Amount Per Pay Period (TDR)		Acrobat PDF		Use to calculate your contribution amount per pay period if you want to contribute your maximum amount
	TIAA-CREF Beneficiary Form		Acrobat PDF		Use to designate beneficiary
	Vanguard Beneficiary Form		Acrobat PDF		Use to designate beneficiary
	Visit www.hr.upenn.edu/retirement or call the Retirement Call Center at 1-877-PENN-RET (1-877-736-6738) to enroll for the TDR plan.

 

	Calculating Your Maximum Contribution Amount Per Pay Period (SRA)		Acrobat PDF		Use to calculate your contribution amount per pay period if you want to contribute your maximum amount
	TIAA-CREF Beneficiary Form		Acrobat PDF		Use to designate beneficiary
	Vanguard Beneficiary Form		Acrobat PDF		Use to designate beneficiary
	Visit www.hr.upenn.edu/retirement or call the Retirement Call  Center at 1-877-PENN-RET (1-877-736-6738) to enroll for the SRA plan.

 

	Use the online tuition management system to apply for and manage tuition benefits for you, your spouse/same-sex domestic partner, and your children.

 

	Davis Vision Claim Form		Acrobat PDF

Compensation Forms

	Position Information Questionnaire (PIQ) - Short Form		Acrobat PDF Word 97/2000
	Position Information Questionnaire (PIQ)		Acrobat PDF Word 97/2000
	Position Information Questionnaire (PIQ) - IT Group Supplement		Acrobat PDF Word 97/2000
	Position Description Form		Acrobat PDF Word 97/2000
	Timesheet  (see Policy 302)		Word 97/2000
	Overtime Authorization Form (see Policy 302)		Word 97/2000

Recruitment and Staffing Forms

	Employment Application		Acrobat PDF
	Temporary Employment Application		Acrobat PDF

	Background Check Authorization Form		Acrobat PDF Word 97/2000
	Background Check Authorization Form (Temp)		Acrobat PDF Word 97/2000
	Candidate Evaluation Form		Word 97/2000 Acrobat PDF
	Candidate Matrix		Word 97/2000 Acrobat PDF
	Emergency Evacuation Form		Acrobat PDF
	Employee Reference Check Form		Acrobat PDF
	External Candidates on Grant Funding		Acrobat PDF Word 97/2000		Sample Offer Letter
	External Candidates Not on Grant Funding		Acrobat PDF Word 97/2000		Sample Offer Letter
	I-9 Form		Acrobat PDF
	Internal Candidates on Grant Funding		Acrobat PDF Word 97/2000		Sample Offer Letter
	Internal Candidates Not on Grant Funding		Acrobat PDF Word 97/2000		Sample Offer Letter
	Salary Setting Worksheet		Word 97/2000
	Salary/Start Date Authorization Request Form		Acrobat PDF		Authorization request sent to Recruitment & Staffing before making an offer of employment
	Temporary Worker Sample Hire Letter		Word 97/2000
	W-4 Form		W-4 form

	Relocation forms page		Relocation Forms homepage		Relocation forms are located on a separate page for security reasons; you will be asked to enter your PennKey and password before accessing them

Staff and Labor Relations Forms

	Application for Staff Grievance Panelist		Acrobat PDF		Application
	Paid Time Off Worksheet		Acrobat PDF Excel 97/2000		Worksheets to assist in determining your paid time off balance.
	Request for Time Off Form		Acrobat PDF		Form used to request time off from work.
	Introductory Period Performance Plan		Acrobat PDF Word 97/2000
	Performance and Staff Development Plan for All Staff		Acrobat PDF Word 97/2000
	Performance and Staff Development Plan - Short Form (for Monthly and Weekly Paid Staff)		Acrobat PDF Word 97/2000		Short Form
	Performance and Staff Development Plan - Letter Template (for Monthly and Weekly Paid Staff)		Acrobat PDF Word 97/2000		Letter Template
	Performance and Staff Development Plan - Memorandum Template (for Monthly and Weekly Paid Staff)		Acrobat PDF Word 97/2000		Memorandum Template
	Performance and Staff Development Self-Appraisal Worksheet (For All Staff)		Acrobat PDF Word 97/2000
	Performance and Staff Development Comment Sheet (optional)		Acrobat PDF Word 97/2000
	Grievance Panel Review Request Form		Acrobat PDF
	Family and Medical Leave (FMLA) Provisional Letter #1 - Policy 631		Word 97/2000		Staff member has been out sick for more than 3 consecutive days and has not notified you.
	Family and Medical Leave (FMLA) Provisional Letter #2 - Policy 631		Word 97/2000		Staff member has notified you s/he will be out for possible FML qualifying event for his/her own serious medical condition.
	Family and Medical Leave (FMLA) Provisional Letter #3 - Policy 631		Word 97/2000		Staff member has notified you s/he will be out for possible FML qualifying event to care for family member with a serious medical condition.
	Family and Medical Leave (FMLA) Provisional Letter #4 - Policy 631		Word 97/2000		Staff member has notified your s/he will be out for possible FML qualifying event for birth/placement of a child for adoption.

Quality of Worklife Forms

	Sample Flexible Work Option Proposal		Acrobat PDF Word 97/2000		Lays out a plan for implementing a Flexible Work Options arrangement
	Sample Flexible Work Option Arrangement Agreement		Acrobat PDF Word 97/2000		Clarifies the specifics and expectations of the agreed-upon Flexible Work Options arrangement
	Sample Flexible Work Option Agreement Addendum		Acrobat PDF Word 97/2000		Defines the terms and conditions of a Flexplace agreement