Southeast Missouri State University

The following forms are intended for employees of Southeast Missouri State University. Please click the appropriate category to obtain the proper form: Benefits, Job Evaluation & Compensation, Employment, Foreign National, Human Resources Records, Leave, New Employee, Pay Related, Performance Appraisal, Personnel Actions, Separation and Workers' Compensation.

Benefit Forms

For more information about these forms and their use, call x2855.

Authorization for Release of Information
(Microsoft DOC), (Adobe PDF)
Release form to allow Human Resources to discuss protected health information

Change of Beneficiary on Life Insurance Form
(Microsoft DOC), (Adobe PDF)
Change life insurance beneficiary

Cooperative Doctoral Program Agreement
(Microsoft DOC), (Adobe PDF)
Cooperative Doctoral Program Enrollment Agreement

Cooperative Graduate Program Reimbursement Form
(Microsoft DOC), (Adobe PDF)
Request reimbursement on Cooperative Graduate coursework

Dependent Tuition Reimbursement Application and Criteria
(MySoutheast), (Directions)
Request dependent's participation in undergraduate coursework for reimbursement

Employee Tuition Fee Waiver
(MySoutheast), (Directions)
Request employee's fee waiver for undergraduate and graduate coursework

HSA Form Trustee-to-Trustee
(Adobe PDF)
Form used to rollover Mellon HSA balance into OptumHealthBank HSA

HSA Rollover Transfer Form
(Adobe PDF)
Form used to rollover or transfer of HSA assets currently held by another custodian/trustee to OptumHealth Bank

Medical Excuse Verifications
(Microsoft DOC), (Adobe PDF)
Sick leave verification

Medical Insurance Opt Out Form
(Microsoft DOC), (Adobe PDF)
Elect not to participate in University's medical insurance

Medical Reimbursement Account/Dependent Care Assistance Program Reimbursement Form
(Adobe PDF)
Request reimbursement for medical or dependent care expenses from your existing flexible spending account

Medical Reimbursement Account Direct Deposit Authorization Form
(Adobe PDF)
Direct deposit election form for BMI

MSEP 2011 Contribution Beneficiary
(Adobe PDF)
Form used by members that wish to designate a beneficiary for their member contributions

MSEP 2011 Refund of Contribution Application
(Adobe PDF)
Form used by members that have terminated employment and wish to withdraw their contributions and forfeit their prior service

OptumHealth Bank Designation of Beneficiary
(Adobe PDF)
Form used to designate a beneficiary of your OptumHealth Bank HSA account

OptumHealth Bank Schedule of Fees
(Adobe PDF)
Fees associated with your OptumHealth Bank HSA account

OPTUMRx Order Form
(Adobe PDF)
Form used to order your prescription drugs using mail-order services

Prescription for Over-the-Counter Medication
(Adobe PDF)
Form used to accompany all requests for reimbursement for over-the-counter drugs and medicines

Salary Reduction Form - Tax Sheltered Annuities
(Microsoft DOC)
Request a new or change in your TSA reduction amount

Salary Reduction Form - Health Savings Accounts (HSA's)
(Microsoft DOC)
Request a new or change in your HSA reduction amount

Job Evaluation & Compensation

For more information about these forms and their use, call x2206.

Clerical/Service Job Description Questionnaire
(Word, Adobe PDF)
Write up clerical and service job descriptions

Administrative/Professional/Technical Job Description Questionnaire
(Word, Adobe PDF)
Write up administrative, professional and technical job descriptions

Evaluation Request Form for Clerical/Service Jobs
(Word, Adobe PDF)
Request an evaluation of current clerical and service job descriptions

Evaluation Request Form for Administrative/Professional/Technical Jobs
(Word, Adobe PDF)
Request an evaluation of current administration, professional and technical job descriptions

Employment

For more information about these forms and their use, call x2080 (Faculty) or x5096 (Staff).

Faculty Search Process
(Adobe PDF)
Step by step instructions for completing the faculy search process using NEOGOV

Faculty Recruitment Plan
(Adobe PDF)
Recruitment plan for faculty positions

Staff Search Procces
(Adobe)
Step by step instructions for completing the staff search process using NEOGOV

Staff Recruitment Plan
(Adobe PDF)
Recruitment plan for staff positions

Employment Application
(Adobe PDF)
Use to apply for custodial and crafts/trades jobs

Personnel Requisition
(Adobe PDF)
Request to hire temporary employee

Foreign National

For more information about these forms and their use, call x2855.

Foreign National Information Form
(Adobe PDF)
Tax determination for international employees

Internal Request Form to Process H1B Petition
(Microsoft DOC), (Adobe PDF)
Request a H1B Petition

Human Resources Records

For more information about these forms and their use, call x2206.

Fee Schedule for Requested Information
(Microsoft DOC), (Adobe PDF)
Calculate fees for requests of public information

Label Request (Internal Use only)
(Adobe PDF)
Request label lists for mailings on campus

Personal Data Change Form
(Microsoft DOC), (Adobe PDF)
Change employee's personal information: name, telephone, address, and other personal information

Leave Forms

For more information about these forms and their use, call x2206.

FML Employee Rights and Responsibilities
(Adobe PDF)

FML Medical Certification for Employee
(Adobe PDF)

FML Medical Certification for Covered Service Members
(Adobe PDF)

FML Medical Certification for Family Members
(Adobe PDF)

New Employee

For more information about these forms and their use, call x2080 (Faculty) or x5096 (Staff).

Appointment Memorandum
(Microsoft DOC), (Adobe PDF)
Temporary new hire/changes in job assignments

Background Check Consent Form
(Adobe PDF)
Consent form for conducting background on employees working with students or handling money

Direct Deposit Authorization Form
(Microsoft DOC), (Adobe PDF)
Set up direct deposit

Employment Eligibility Verification (I-9 Form)
(Adobe PDF)
Verification of employment eligibility

Federal W-4 Tax Form
(Adobe PDF)
Elect federal withholdings

Foreign National Information Form
(Adobe PDF)
Tax determination for international employees

Missouri W-4 Tax Form
(Adobe PDF)
Elect state withholdings

Personal Data Sheet Form
(Adobe PDF)
Personal Data on new hires

Pay Related

For more information about these forms and their use, call x2085.

Additional Payment (AP) Form
(Adobe PDF)
Process an additional payment for an employee for work outside their normal duties

Additional Payment (AP) Form Instructions
(Adobe PDF)
Instructions for Additional Payment Form

Bi-Weekly Leave Correction Report
(Microsoft DOC)
Used by Clerical, Technical, Service and Skilled Crafts employees to correct amount of leave on timesheet

Bi-Weekly Student Payroll Timesheet
(Adobe PDF)
Used by Student employees to enter time, per department request

Direct Deposit Authorization Form
(Microsoft DOC)
Revise Direct deposit for paycheck. Mandatory for all regular employees and strongly encouraged for temporary and student employees.

Earned Income Credit Form (W-5)
(Adobe PDF)
Internal Revenue Service form for eligible employees. Instructions are included.

Earnings Request Form
(Microsoft DOC), (Adobe PDF)
Request payment for an employee regular time entry window

Employee Payroll Deduction Form
(Adobe PDF)
Used by employees to initiate deductions from employee paychecks for various fees

Faculty Pay Plan Form
(Microsoft DOC), (Adobe PDF)
Faculty may elect either the 10 or 12 month payment plan

Labor Distribution Reallocation Form
(Microsoft DOC), (Adobe PDF)
Reallocate labor expenses from one account to another. Questions: call (573) 986-6192

Monthly Leave Adjustment Report
(Microsoft DOC)
Used by Administrators, Professional Staff and Faculty to correct amount of leave on timesheet

State of Missouri Tax Form
(Adobe PDF)
Form to elect state withholdings

W-2 Copy Request Form
(Microsoft DOC), (Adobe PDF)
Form to request additional copies of W-2

W-4 (Federal)
(Adobe PDF)
Form to elect federal withholdings

Withholding Calculator (Federal)
Link: IRS.gove website
Federal withholding calculator

Withholding Calculator (State)
Link: Missouri Department of Revenue
State withholding calculator

Vacation Buyback Request

(AdobePDF) Used by Union Employees to request vacation buyback hours

Performance Appraisal

For more information about these forms and their use, call x6192.

Performance Appraisal Instructions/Appeals
(Microsoft DOC), (Adobe PDF)
Performance appraisal instructions and appeals process

Performance Evaluation Procedures
(Adobe PDF)
Detailed procedures for each level of evaluation

Clerical/Technical/Service Staff Performance Appraisal
(Microsoft DOC), (Adobe PDF)
Performance appraisal for clerical, technical and service staff

Admin/Prof Staff Performance Appraisal
(Microsoft DOC), (Adobe PDF)
Performance appraisal for administration and professional staff

Executive Staff Performance Appraisal
(Microsoft DOC), (Adobe PDF)
Performance appraisal for executive staff

Personnel Actions

For more information about these forms and their use, call x2407.

Continuing Term Assignment Template
(Microsoft DOC), (Adode PDF)
Renew term assignments

Labor Distribution Change Template
(Microsoft DOC), (Adode PDF)
Change labor distribution charges

Leave of Absence With Pay Template
(Microsoft DOC), (Adode PDF)
Initiate leave with pay

Leave of Absence Without Pay Template
(Microsoft DOC), (Adode PDF)
Initiate leave without pay

Other Change Template
(Microsoft DOC), (Adode PDF)
Miscellaneous changes

Rehire Template
(Microsoft DOC), (Adode PDF)
Rehire temporary employees

Return from Leave of Absence Template
(Microsoft DOC), (Adode PDF)
Initiate return from leave of absence

Termination (Temporary employees) Template
(Microsoft DOC), (Adode PDF)
Terminate temporary employees

Separation

For more information about these forms and their use, call x2084.

Staff Property Clearance Form
(Adode PDF)
Verify terminating employee's financial obligations to the university

Faculty Check-out Procedures
This check-out form may be found under "Faculty Forms" on the Office of the Provost web page.

Termination Report Form

(Adode PDF)
Report employee termination

Workers' Compensation

For more information about these forms and their use, call x2084.

Authorization to Release Medical Records
(Adode PDF)
Release medical records to CARO; form is completed by injured employee

Employee Injury Report
(Adode PDF)
Report injury; form is completed by injured employee

Supervisor Statement
(Adode PDF)
Report injury; form is completed by supervisor

Vendor Input Form
(Adode PDF)
Provide contact information; form is completed by injured employee

Witness Statement
(Adode PDF)
Witness to the accident of the injured employee; form is completed by witness.

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