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
(Adobe PDF)
Write up clerical and service job descriptions
Administrative/Professional/Technical Job Description Questionnaire
(Adobe PDF)
Write up administrative, professional and technical job descriptions
Evaluation Request Form for Clerical/Service Jobs
(Adobe PDF)
Request an evaluation of current clerical and service job descriptions
Evaluation Request Form for Administrative/Professional/Technical Jobs
(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).
Creating a Personnel Requisition
(Adobe PDF)
Step by step instructions for creating a personnel requisition in NEOGOV to begin the employment search process
Approving a Personnel Requisition
(Adobe PDF)
Step by step instructions to approve a personnel requisition in NEOGOV
Search Process
(Adobe PDF)
Step by step instructions for completing the search process using NEOGOV
Faculty Recruitment Plan
(Adobe PDF)
Recruitment plan for faculty positions
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.