Forms

Evaluations

Academic Employees, Evaluations

Coach Performance Evaluation Form
Personnel Data Sheet Form Updated April 2022.
Professional Development Plan Form The Professional Development Plan (PDP) is a flexible document that reflects the strengths of the candidate and her/his professional development goals.
Range Elevation Portfolio (REP) Coverpage For use by Lecturers seeking Range Elevation

Benefits

*HCRA/DCRA Claim Form Attach supporting documentation and submit to ASIFlex
Authorization to Transport Form Request for Non-Emergency Medical Transportation for Work-Related Injuries
Benefits Enrollment Worksheet
CAL-ORE Membership Application A Cal-Ore Life Flight membership ensures the patient will have no out-of-pocket flight expenses if flown by the Company or another AirMedCare Network participating provider
Career Development Plan Career Development Plans use an online submission process which provides the opportunity to sign, gain signatures and submit electronically.
Catastrophic Leave Donation Form - Family Care
Catastrophic Leave Donation Form - Self
Claim Form DWC1
Employee’s Report of Injury (DWC-1) – Must be given to employee at the time injury is reported to Supervisor, or as soon as possible after medical treatment is received
Fee Waiver Application - Dependent
Fee Waiver Application - Self
Fee Waiver Application Fee Refund Request
Leave Without Pay (LWOP) Application (staff/management)
Out-of-Network Reimbursement Form
Pre-Designation of Physician Form
Predesignation of a Personal Physician
Savings Plus Benefits Payment Booklet
This booklet contains information and a payment application to help you select the payment method that best meets your needs.
SPSL Request Form
Employee will need to initiate the form and send it to supervisor for review/approval. Supervisor will need to send the completed form to mca33@humboldt.edu. Please make sure the time is also claimed in Absence Management or claimed on the employee's timesheet
Supervisor's Report of Injury
Supervisor’s Report of Injury – MUST BE SUBMITTED TO HUMAN RESOURCES WITHIN 24 HOURS OF KNOWLEDGE OF INJURY
The Standard Beneficiary Form
Employer Paid Life and AD&D Beneficiary Designation and Change Form
Video Display Terminal (VDT) Claim Form
The VSP Video Display Terminal (VDT) Confirmation Form is only provided to CSU employees who meet the necessary job requirements as determined by the CSU campus benefits office. This form must be completed by the employee and provided to a VSP Select Network doctor to receive the supplemental VDT benefit.
VSP Premier Enrollment Form
This is an Adobe Sign Form. You will need to log in with your Humboldt username account. Follow the instructions in the landing page.
Work-Related Injury Reporting Procedure
The document includes links to all the necessary forms for the Workers' Compensation process.

Academic Employees, Benefits

Form 310 - Difference in Pay (DIP) Leave Application
Available to eligible faculty unit employees only.
Form 320 - Sabbatical Leave Application
Available to eligible faculty unit employees only.
Form 900 - Request for Participation in Faculty Early Retirement Program (FERP)
Tenured Faculty Unit employees who are of normal retirement age (consistent with CalPERS rules and pursuant to the California Code of Regulations (CCR) §586.1) are eligible to participate in the program.
Sabbatical/DIP Notary Pages
Notary Pages for Approved Sabbatical and DIP Leaves

Equal Opportunity and Compliance

Executive Order 1083: Attachment A
Acknowledgement of Mandated Reporter Status and Legal Duty to Report Child Abuse and Neglect (EO 1083)
Executive Order 1083: Attachment C
California law requires certain people, known as “Mandated Reporters,” to report known or suspected child abuse or neglect. You have been identified as a certain type of Mandated Reporter: a Limited Reporter under Penal Code § 11165.7(a)(41). As a Mandated Reporter, you are required by the law to sign this statement acknowledging your legal reporting obligations.
Executive Order 1083: Attachment D
Child Abuse Reporting Form
Executive Order 1083: Attachment E - Suspected Child Abuse Report
To Be Completed by Mandated Child Abuse Reporters Pursuant to Penal Code Section 11166
Form 801
This form is used to report certain payments received by state and local government agencies. It includes: • a payment for an official’s travel expenses for the purpose of facilitating the public’s business in lieu of a payment using agency funds; and • a payment that would otherwise be considered a gift or income to the benefiting official, but is instead accepted on behalf of the agency.
Whistleblower Complaint Form
This complaint form is to be used to file a Protected Disclosure of Improper Governmental Activities and/or Significant Threats to Health or Safety under Executive Order 929.
Whistleblower Online Complaint
The California Whistleblower Protection Act authorizes the California State Auditor to receive complaints from state employees and members of the public who wish to report an improper governmental activity. Note: Complaints are not accepted via email.

Onboarding

Application for a Social Security Card
Apply for an original Social Security card, apply for a replacement Social Security card, change or correct information on your Social Security number record
CalPERS Member Reciprocal Self-Certification FormThe Reciprocal Self-Certification form allows you to provide essential information to your employer and will be used by your employer to enroll you into CalPERS membership.
CMS / PeopleSoft Access Form
The Account Request process is used to add, modify, or delete a person's (user or developer) access to PeopleSoft Human Resources, PeopleSoft Campus Solutions, Customer Relationship Management, PeopleSoft Finance, and/or OBI enterprise applications.
Designation of Person Authorized to Receive Pay
Important: This is NOT a designation for payment of death benefits and refund of employee retirement contributions.
Direct Deposit Form
To enroll in Direct Deposit, complete this form.
EIF - Payroll Designee
Use this form ONLY to change payroll designee. Employee starts the Adobe Sign Workflow.
Employee Action Request - UPDATES ONLY (EAR Form)
NOTE: USE THIS FORM FOR UPDATES ONLY- This form is required from the State and is used prior to employment or to make changes during employment, for determining exemption status for taxable deductions, and any other deductions sought. This form is also used for address & withholding changes.
Form 104 - Report of Appointment for Special Consultants, Casual Workers and Extending Temp Appointments
We recommend that you use Firefox or Chrome for this form. Internet Explorer may experience slow page loads.
Form W-4 - Employee's Witholding Allowance Certificate
This is used for employees' information only. It does not replace the EAR or SPAR forms.
Job Hazard Analysis (JHA) Form
New Employee Sign-Up Chain of Custody Agreement
We recognize that there are situations when a department will need to assist a new employee (e.g. Student Assistant or Special Consultant) with their sign-up documents. When a department commits to this responsibility, the designated person or persons commits to the proper handling of sensitive data.
Policy List Receipt Form
List of some of the important policies that you should be familiar with. Signature needed indicating that you received this document.
Position Change Form
Please use when funding changes are needed for current employees.
Special Consultant Request
Student Payroll Action Request (SPAR)
NOTE: DO NOT USE THIS FORM FOR NEW STUDENTS. Use this form for Student Assistants and Work Study Payroll updates such as address change, name change, birthdate change, withholding allowance change and ethnic correction.
Summer Bridge - Employee Action Request
Summer Bridge - Employee Information Form
Summer Bridge Student Assistant Appointment Form
Please send the complete form as an attachment to an email to payroll@humboldt.edu specifying your approval. No signature necessary for 2020.
Volunteer Form
NOTE: DO NOT send the link to the volunteer. Follow the procedure in the Form's notes.

Onboarding, Payroll

COVID19 Summer Bridge Student Workbook

Offboarding, Onboarding

Form 107: Application for Leave of Absence
Application for Leave of Absence for Staff and Management Employees - Please print on pink paper
Form 107: Application for Leave of Absence
Application for Leave of Absence for Staff and Management Employees - Please print on pink paper

Offboarding

Form 109 - Report of Separation for Staff & Managers
Do not use this form for Faculty
Form 510 - Advice of Separation: Lecturer, FERP, Temp Librarian, TA & GA
Separation form for Part-time and Full-time Lecturers, FERP participants, Teaching Associates and Graduate Assistants. Submit to Payroll and APS by effective date of separation, or deadline set by APS, whichever is earlier. This document allows Payroll to inactivate temporary academic employees whose appointments have ended and avoid overpayments.
Form 515 - Advice of Separation: Coaches, Counselors (SSP-AR & Interns), Librarians
Completed each semester in accordance with the deadlines set by Academic Personnel Services, or upon separation/end date of appointment. This document allows Payroll to inactivate temporary faculty unit employees whose appointments have ended.
Form 610 - Advice of Separation: Instructional Student Assistants
Completed each semester in accordance with the deadlines set by Academic Personnel Services or as needed throughout the term. This document allows Payroll to inactivate temporary academic student employees whose appointments have ended.
Manager's Digital Resources Checklist for Separating Employees
Checklist to assist managers in identifying digital resources that require attention when an employee separates from their unit or the University, including leaves of absence.
Separating Clearance Form - Management
Separating Employee Clearance Form
Must be completed before final pay check is issued. This Form IS NOT for continuing FERP or Reappointed Faculty/Staff.
Separating Employee Clearance Form - Housing & Dining Services
This form must be completed before final pay check is issued.
Temporary Telecommuting Agreement
NOTE: DO NOT SEND LINK TO EMPLOYEES - Instead fill out the form with the staff member and appropriate administrator emails and names and hit the Send button.

Recruitment

*Employment Release of Information Form
***This form is only required if you don't use the "Request to Applicant for References" status in CHRS Recruiting - PageUp.*** Committees are encouraged to utilize the "Request to Applicant for References" status in CHRS Recruiting-PageUp as it will automatically prompt the candidate for additional information and alert the them that the committee intends to begin reference checks shortly. If needed, please obtain signed release of information form from candidate during their on-campus interview.
*Reference Check Information for Recommended Candidate Form
The reference check forms will be submitted after moving the selected candidate(s) to the "Reference Check Successful/Recommendation to Dean for Hire" status in CHRS Recruiting (PageUp). Please be sure to document the the candidate's strengths and weaknesses in PageUp's "Search Committee Panel Review" section before you move your candidate(s) to the "Reference Check Successful/Recommendation to Dean for Hire". Please reach out to APS via email with any questions, aps@humboldt.edu.
*Vacancy Announcement Template - Probationary Faculty
Vacancy Announcement Template for Probationary Faculty Unit Employee Positions
*Vacancy Announcement Template - Temporary Faculty Unit Employee
Confidentiality Acknowledgement & Agreement for Search/Screening Committee Members & Staff - Faculty Unit Positions
Signed by all committee members and support staff for a Faculty Unit search to acknowledge and agree with specified confidentiality provisions.
Confidentiality Form for Search Committees for Dean/Associate Dean
Signed by all committee members and support staff for an Academic Dean/Associate Dean search to acknowledge and agree with specified confidentiality provisions
Employment Release of Information Form
Use only when an Humboldt application is not required.
Form 200: Position Request - Probationary Faculty Unit Employee
During each academic year, a schedule is established for the submission of Probationary Faculty Unit Employee recruitment requests. Department must fill out Form 200: Position Request (Probationary Faculty Unit Employee) with required attachments for each position desired and submit it for review and approval.
Form 400 - Recommendation for Faculty Unit Appointment (Tenure-line)
Form 450 - Probationary/Tenured Faculty Workload Distribution Form
Use for tenure-track faculty wishing to distribute workload over three terms
Form 540: Temporary Librarian Transaction Form
Use for temporary Librarian new appointments, revisions, or reappointments
Form 560 - Temporary Counselor Transaction Form
Use for temporary Counselor new appointments, revisions, or re-appointments
Form 570: Substitute Faculty Assignment
Use for assigning paid short-term substitute faculty
Form 590: Application for Temporary Appointment - Coaches/Counselors/Librarians
To be used by new applicants. Application will be kept on file for 3 years.
Form 595: Request for Subsequent Appointment - Coaches/Counselors/Librarians
To be submitted annually by current coaches, counselors and librarians to request a subsequent appointment.
Form 600: Instructional Student Assistant (ISA) Appointment Form
The Submitter (generally an ASA/ASC in the department) will be entering and submitting the appointment detail into the e-Form 600. After the e-Form 600 has been submitted, an e-mail will be sent to the Submitter with a link to the form so he/she may track the status.
Form 630: Description of Duties
Must be given to Academic Student Employee (ASE) at time of appointment; send electronic copy to Academic Personnel Services to be kept on file.
Form 640: Unit 11 Evaluation Criteria
A written assessment for Academic Student Employee (ASE) performance. A blank copy of this evaluation form must be given to the ASE within the first fourteen (14) days of appointment if an evaluation is to take place.
Form 800 - Volunteer Faculty: Recommendation for Appointment
HR 2016-06 MPP Outside Employment Disclosure Form
For MPP Employees Only
Reference Check Information for Recommended Candidate Form
NOTE: Move to Forms Site
Reimbursement Request
Use only when a department is paying for travel expenses of interviewed candidates.
Screening Matrix: Minimum Qualification & Application Material Review Spreadsheet
Complete the provided Screening Matrix by addressing the minimum qualifications listed on the posted vacany announcement. Submit form to APS when moving selected candidate(s) to the "Request to Interview - Telephone/Zoom (APS Approval Required)" status in CHRS Recruiting (PageUp). For Academic Searches Only.
Staff/MPP Vacancy Announcement Template
Strategic Advertising/Recruitment Plan
May be useful for committees to review prior to submitting their request to recruit Google Form. APS will build position in CHRS Recruiting (PageUp) and obtain quotes from advertising partners. For Academic Positions Only.
Student Assistant Performance Evaluation
Supplemental Application for Employment
Temporary Faculty Coach Justification Form
For use by the Athletics Department, to be attached to temporary faculty coach appointment paperwork for a new hire.
Vacancy Announcement Template - Graduate Assistant (GA)
All ASE positions must be advertised. Positions may be advertised as ongoing, with updates only as needed when requirements or assignments change.
Vacancy Announcement Template - Teaching Associate (TA)
All ASE positions must be advertised. Positions may be advertised as ongoing, with updates only as needed when requirements or assignments change.

Compensation and Classification

MPP Justification Form
The CSU requires written justifications for both the purpose and specific number of proposed additional management positions. When filling a vacant but existing MPP position, while the form must be completed it is only necessary to indicate: the position exists, working title, the past incumbent is no longer employed with CSUB and the existing duties will continue.
Position Description Form
A Position Description describes the knowledge, skills, abilities, and duties of a specific position, not the characteristics or traits of the current incumbent.
MPP Justification Form
The CSU requires written justifications for both the purpose and specific number of proposed additional management positions. When filling a vacant but existing MPP position, while the form must be completed it is only necessary to indicate: the position exists, working title, the past incumbent is no longer employed with CSUB and the existing duties will continue.
Position Description Form
A Position Description describes the knowledge, skills, abilities, and duties of a specific position, not the characteristics or traits of the current incumbent.
Staff Compensation and Classification Request Form

Quick Links

Site Search

Breadcrumb

Forms

Evaluations

Academic Employees, Evaluations

Benefits

Academic Employees, Benefits

Equal Opportunity and Compliance

Onboarding

Onboarding, Payroll

Offboarding, Onboarding

Offboarding

Recruitment

Compensation and Classification

Payroll