Maytum Hall administration building on the Fredonia campus.

HR Forms

Health Insurance

NYS Health Insurance Transaction Form (PS-404) - PDF
NYS Health Insurance Opt-Out Attestation (PS-409) - PDF
NYS Health Insurance Domestic Partner Packet (PS-425 series) - PDF
Pre-Tax Contribution Program Fact Sheet - PDF


Retirement Program History & Election Forms - PDF

Employees' Retirement System (ERS):

  • ERS Membership Application - PDF
  • ERS Designation of Beneficiary Form - PDF

Teachers Retirement System (TRS):

  • TRS Membership Application - PDF

Optional Retirement Program (ORP):

  • ORP to ERS System Determination Form (ORP-4) - PDF

Other Benefits

B-140W Application for Tuition and Fee Assistance - PDF
Breast Cancer Screening Leave - PDF
Group Long Term Disability Insurance Program - PDF
Prostate Cancer Screening Leave - PDF

Request for Appendix A-28 Promotion and/or Salary Increase (UUP) - PDF

Address/Telephone/Name Change Form - PDF
Agility Waiver and campus map for University Police 1 Applicants
Authorization for Release of Health Information Pursuant to HIPAA - PDF
Bereavement Form - PDF
Employment Eligibility Verification (I-9)
Information Release Form - PDF
Leave Donation To Individual - PDF
Leave Donation To Sick Leave Bank - PDF
Leave of Absence (Family or Medical) *Employees must contact Human Resources for consultation*
Family & Medical Leave Request Form - PDF
Medical Certification Forms - WH-380-E, WH-380-F, WH-381, WH-382
Medical Certification Form in Response to an Accommodation Request - PDF
Voluntary Reduction in Work Schedule (VRWS) Application - PDF
Voluntary Reduction in Work Schedule (VRWS) Schedule for Use of VR credit - PDF


Classified Staff: If you have been permanently transferred appointed or reinstated to a new agency and your name is on an interdepartmental promotion eligible list(s), use this form (S-211.1) to request to have your name placed on your new agency’s departmental portion of the interdepartmental promotion eligible list(s)

Appendix A: Department Personnel Committee (DPC) Ballot - Word | PDF
Appendix B: Academic Personnel Committee (APC) Ballot - Word | PDF
Appendix C: Conflict of Interest (COI) Form - Word | PDF
Appendix D: Suggestions for Preparing a Dossier for Reappointment, Continuing Appointment, or Promotion - PDF
Appendix E: Performance Program Form - Click Here
Appendix F: Performance Evaluation Form - Click Here
Appendix G: Request to Pause the Tenure Clock - Word | PDF
Appendix H: Request to Pause the Permanent Appointment Clock - Word | PDF
Appendix I: Emeritus Application - Google Form
Appendix J: Request for Prior Service Credit - Academic Position - Word | PDF
Appendix K: Request for Prior Service Credit - Non-Teaching Professional Position - Word| PDF
Appendix L: Classroom Observation Pre-Visit Questionnaire - Click Here
Appendix M: Classroom Observation Feedback Form - Click Here
Appendix N: Classroom Observation Post-Visit Questionnaire - Click Here
Appendix O: Request for Appendix A-28 Promotion and/or Salary Increase - PDF

Dual Employment Form, UP-8 - PDF