Resources & Tools

• Benefits Cost Worksheet

Claim Forms

• Delta Dental Plan Claim Form
• Medical Claim Form
• Prescription Drug Reimbursement Form / Coordination of Benefits Claim Form
• Superior Vision Plan Claim Form
• UT FLEX Health Care Reimbursement Claim Form

Life & Accidental Death and Dismemberment (AD&D)

• Accidental Death & Dismemberment Certificate
• Group Term Life Certificate

Benefits - Miscellaneous Forms

• Affiliated Postdoctoral Fellow/Graduate Student
  Sponsoring Faculty Form
• Direct Transfer Form
• Incapacitated Child Form
• Tobacco Premium Program Declaration Form
• Waiver of Medical Insurance
• Zip Code Exception Form

UT FLEX

• UT Flex Dependent Care Reimbursement Claim Form
• UT Flex Letter of Medical Necessity Form
• UT Flex Health Care Reimbursement Claim Form

UT Select BCBS

• Coordination of Benefits

• Investment Policy Statement
• Purchase/Change Agreement
  Use to change provider(s) for future retirement contributions
• UT Vesting/Termination Status Form

Optional Retirement Program - ORP

• Authorization for Reduction for Employee Contribution
  Use for initial ORP election
• Authorization for Reduction for Employee Contribution for Employees Returning to ORP
  Use for ORP election for vested participants returning to employment
• ORP Acknowledgment Form
  Must be signed by all employees who are newly-eligible for ORP
• ORP Declaration of Retirement
• ORP Plan
• Overview of TRS and ORP
• Transfer Verification Form (All plans)
  Use to transfer balances from one provider to another
• TRS Form 28 Election to Participate in Optional Retirement Program and/or Refund
  The TRS 28 must be completed by all participants making their initial ORP election or have an account balance with TRS

Teacher Retirement System - TRS

• TRS Website - Forms

UTSaver Tax-Sheltered Annuity Program - TSA 403(b)

• UTSaver TSA 403(b)
• Tax-Sheltered Annuity Disclosure
  This must be signed before your enrollment into a TSA is effective
• Loan, Hardship and Unforeseeable Emergency Procedures
• Transfer Verification Form
  Use to transfer balances from one provider to another.

UTSaver Deferred Compensation Plan - DCP 457(b)

• DCP Purchase Agreement
  (for Separations only - Vacation Payout to DCP 457(b) account)
• UTSaver DCP 457(b)
• Loan, Hardship and Unforeseeable Emergency Procedures
• Transfer Verification Form
  Use to transfer balances from one provider to another.
• DCP Catch-Up Provision Agreement - This must be signed if utilizing the Special Catch-Up Provision and must be accompanied by the 457(b) catch-up worksheet.

UT Benefits Billing (for Retirement Only) - UTBB

• Direct Payment/Debit Authorization Agreement
• Personal Information & Emergency Contact Form

Position Management

• Job Description Template

Miscellaneous Forms

• Faculty Salary Election Agreement

• Conflicts of Interest Policy Acknowledgement Form
• I-9 List of Acceptable Documents
• Acknowledgment of Service without Salary for POI/Volunteer
• Acknowledgment of Service without Salary for Vendor Only (Independent Contractors)
• Orientation On The Job Checklist
• Promotion/Transfer Policy

Staff Forms

• ECR - Exception/Correction Request Form
• Political Aid, Legislative Influence and Standards of Conduct

Templates / Sample Documents

• Conditional Employment Offer Letter
• Employment Offer Letter
• Interview Questions

Medical

• Medical Leave Checklist
• Request for Leave of Absence
• Sick Leave Pool Application
• FMLA Physician Certification Form
• FMLA Physician Certification Form for Family Member
• FMLA Adult Child Information Form
• Return to Work Release Form
• Sick Leave Pool Donation Form
• Direct Sick Leave Donation - Recipient
• Direct Sick Leave Donation - Donor
• Family Leave Pool Donation
• Family Leave Pool Request

GINA - Genetic Information Nondiscrimination Act of 2008

• EEOC GINA Poster
• GINA FAQ
• GINA Fact Sheet
  Download this form with DOL forms below

DOL - Forms and Resources

• WH-380-E Certification of Health Care Provider for Employee’s Serious Health Condition
• WH-380-F Certification of Health Care Provider for Family Member’s Serious Health Condition
• WH-384 Certification of Qualifying Exigency For Military Family Leave
• WH-385 Certification for Serious Injury or Illness of Covered Servicemember -- for Military Family Leave
• Breastfeeding State Laws
• FAQ - Break Time for Nursing Mothers
• Break Time for Nursing Mothers

The Patient Protection and Affordable Care Act (“Affordable Care Act”) amended section 7 of the Fair Labor Standards Act (“FLSA”) to require employers to provide “reasonable break time for an employee to express breast milk for her nursing child for one year after the child’s birth each time such employee has need to express the milk.”

As such, UTSA supports moms in the efforts to both work and continue breastfeeding by providing a place, other than a bathroom, that is shielded from view and free from intrusion from coworkers and the public, which may be used to express breast milk. See the attached link for more information. http://www.dol.gov/whd/nursingmothers/

For assistance in making arrangements, please contact Leave Administration at  HR@utsa.edu

Leave Administration Miscellaneous Forms and Resources

• Families First Leave Application
• Application for Wellness Incentive - Additional Leave
• Wellness Incentive - Additional Leave Fact Sheet
• UTSA Holidays
• Vacation Accrual Rates

• Prior State Service and Release of Student Employment Records
• Change of Address/Telephone or other Contact information
  An employee who is currently employed at UTSA can change their contact information via the Employee Self Service feature in PeopleSoft.
• A former employee or retiree who wishes to make changes to their contact information must contact People Excellence by email HR@utsa.edu or by phone 210-458-7210.

• Acceptance of Resignation Letter (Template)
• Employee Separation Process - Administrator Guidelines
• Separation Processing Checklist

• Class Evaluation Form
• Individual Sign-in Sheet
• Sign-in Sheet