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Form

Description

Campus

Academic Student Employee Letter Academic departments use this template to write a letter to send to potential new employees.
Submit to: ELR Department
UC Davis
Access Violation Report Department fills out form when employee organizations commit unauthorized or illegal actions.
Submit to: ELR Department
UC Davis
Background Check Authorization
(UC Davis)
Certain positions at UC Davis require a successful background check as condition of employment.
Submit to: Hiring Manager
UC Davis
Background Check Authorization
(UC Davis Health)
Certain positions at UC Davis Health require a successful background check as condition of employment.
Submit to: Shared Services Organization, Recruitment coordinators
UC Davis Health
Background Check Worksheet For department heads to list reasons for background check.
Submit to: Hiring Manager
UC Davis / UC Davis Health
Catastrophic Leave - Application UC Davis Health employees should use this form to apply for catastrophic leave.
Submit to: Department Manager or Chief Administrative Officer.
UC Davis Health
Catastrophic Leave - Worksheet Managers and Chief Administrative Officers complete this form when considering an employee’s request for catastrophic leave.
Submit to: ELR for review and determination.
UC Davis Health
Catastrophic Leave - Permission to Release Medical Records (Exhibit A) In the event that an employee has donated their leave to a colleague, this form allows the university to release a general medical description to support the employee's catastrophic leave request.
Submit to: Department Supervisor
UC Davis
Catastrophic Leave - Request for Donations (Exhibit B) Form through which employees can donate leave time to fellow employees who have exhausted their personal leave options.
Submit to: Department Employees
UC Davis
Catastrophic Leave - Donation Form (Exhibit C) Form through which employees who wish to donate their accrued vacation leave to colleague who have exhausted their own leave options. 
Submit to: Department Supervisor
UC Davis
Child Abuse Notification

Employees must sign this statement if their duties require direct contact with, and supervision of, children.
Submit to: Onboarding coordinator

UC Davis / UC Davis Health
Classification Review Request Complete to request a classification review.
Submit to: Compensation Department - Compensation Analyst
UC Davis Health
Compensatory Time Notification Form (CX Unit) Allows employees in the Clerical and Allied Services Unit (CX) to elect how they receive compensation for overtime.
Submit to: Original to Supervisor, copy to Employee
UC Davis / UC Davis Health
Compensatory Time Notification Form (HX Unit) Allows employees in the Health Care Professionals Unit (HX) to elect how they receive compensation for overtime.
Submit to: Original to Supervisor, copy to Employee
UC Davis / UC Davis Health
Compensatory Time Notification Form (Non-Represented Staff)
Non-exempt employees are entitled to either Over Time or Compensatory Time Off. Comp. Time is allowed at the manager’s discretion. This form allows the employee to opt for CT in lieu of OT if approved.
Submit to: Create AggieService ticket, upload form to ticket, shared services will make the adjustment.
UC Davis / UC Davis Health
Compensatory Time Notification Form (RX Unit) Allows employees in the Research Support Professionals Unit (RX) to elect how they receive compensation for overtime.
Submit to: Original to Supervisor, copy to Employee
UC Davis / UC Davis Health
Compensatory Time Notification Form (SX Unit) Allows employees in the Service Unit (SX) to elect how they receive compensation for overtime.
Submit to: Original to Supervisor, copy to Employee
UC Davis / UC Davis Health
Compensatory Time Notification Form (TX Unit) Allows employees in the Technical Unit (TX) to elect how they receive compensation for overtime.
Submit to: Original to Supervisor, copy to Employee
UC Davis / UC Davis Health
Conditional Offer of Employment Template Supports departments when offering an appointment that is contingent upon a successful background check.
Submit to: Prospective employee
UC Davis / UC Davis Health
Demographic Data Complete this form to provide demographic information for employment.
Submit to: Shared Services Organization, Recruitment coordinators
UC Davis Health
Direct Deposit Election Allows new and rehires to provide banking information for e-direct deposits.
Submit to: Shared Services Organization, Recruitment Coordinators
UC Davis Health
Elder of Dependent Adult Abuse - Employee Notification Certain employees are mandated reporters and must sign this form prior to employment. Hiring departments are required to complete this form during onboarding. 
Submit to: Local HR office
UC Davis / UC Davis Health
Emergency Payroll Advance Request For employees to request an advance on their earnings for any personal emergency reasons.
Submit to: Workers Compensation
UC Davis Health
Employee Complaint Form Allows PSS and MSP employees to file an official complaint.
Submit to: ELR Department
UC Davis / UC Davis Health
Employee Development Worksheet Supervisors use this form for employee evaluations that are not part of the annual performance appraisals.
Submit to: Central HR for scanning; copy given to employee
UC Davis
Employee Separation Complete this form when an employee is separating.
Submit to: Shared Services Organization, UC Davis Health Records Unit
UC Davis Health
Employee-Student Fee Reduction Authorization For employees who are eligible to receive reduced fees. 
Submit to: Obtain the required signatures, then send to the Office of the Registrar by the 10th day of instruction.
UC Davis / UC Davis Health
Employee Time Record Employees can fill out this form to record hours worked prior to online TES/Ecotime account activation.
Submit to: Payroll
UC Davis / UC Davis Health
Employment Eligibility Verification Form (Form I-9) This form is used to verify the identity and legal authorization to work of all paid employees in the United States.
Submit to: Retain in HR personnel file
UC Davis / UC Davis Health
Equity Adjustment Request Complete to request an equity increase. 
Submit to: Compensation/Classification
UC Davis Health
Exceed Maximum Vacation Accrual Limit Request Managers and employees can use this form to when the employee exceeds the vacation accrual threshold.
Submit to: Department Head, then ELR
UC Davis
Flexible Work Arrangements - Policies & Application
Learn about the various flexible work options and use the proposal form to request a flexible work schedule.
Submit to: Employee and supervisor complete the form, save a copy to the department personnel files.
UC Davis
Flexible Work Agreement or Telecommuting
Complete this form to arrange a telecommuting/flexible work schedule for an employee.
Submit to: Shared Services Organization, UC Davis Health Records Unit
UC Davis Health
FMLA Certification of Health Care Provider For employees requesting FML or CFRA to care for a family member, this form documents the family member's qualifying condition.
Submit to: After completion by employee, family member, and family member's health care provider; then submit to department personnel
UC Davis / UC Davis Health
FMLA Certification for Leave Arising out of Active Duty For employees requesting FML for a covered military member being called to active duty.
Submit to: Department
UC Davis / UC Davis Health
FMLA Military Caregiver Leave Certification Employees are Eligible for protected leave to care for the serious injury or illness of a covered service member.
Submit to: Department personnel
UC Davis / UC Davis Health
FMLA Declaration of Relationship Employees are eligible for family medical leave for certain life events that impact relatives. This form helps ensure the relationship is FML eligible.
Submit to: Department personnel
UC Davis / UC Davis Health
FMLA Employee Checklist Helps employees work through the process of requesting family medical leave for certain life events.
Submit to: For employee use only.
UC Davis
FMLA Request Department Checklist Helps departments who aren't under a Shared Services Center to manage employee leave requests.
Submit to: For department use only. 
UC Davis
FMLA Return to Work Certification Employee completes with health care provider and returns completed form to their department, allowing employee to return to work after FML.
Submit to: Employee completes with health care provider and returns completed form to their department.
UC Davis / UC Davis Health
FML, CFRA, Pregnancy Disability Leave (PDL) Designation Notice Allows departments to document if an employee's FML, CFRA, or PDL request has been approved.
Submit to: Department completes form and submits to employee. 
UC Davis / UC Davis Health
FML/PDL Intermittent Tracking Form
Assists departments in tracking intermittent usages of family medical leave (FML) or pregnancy disability leave (PDL).
Submit to: For department use only
UC Davis / UC Davis Health
Interview Rating Scale for Managers & Supervisors For Hiring Departments to use during the interview process. 
Submit to: For supervisor use only
UC Davis
Labor Pool Assistance Request Complete to request labor pool assistance.
Submit to: ELR Department
UC Davis Health
Labor Pool Available Staff Use this form to collect information about employees who are available for the labor pool.
Submit to: Fax to 916-734-3080, attention Labor Pool
UC Davis Health
Leave of Absence Request Form that UC Davis Health employees can use to request an extended leave of absence for certain life events.
Submit to: Manager and/or department personnel liaison.
UC Davis Health
Mandated Reporter Form All UC employees are mandated reporters of any suspected child abuse. This form requires the employee’s signature and informs them of the responsibilities related.
Submit to: Copies to Department personnel file and HR personnel file
UC Davis / UC Davis Health
Medical Separation Review Department uses form to begin the Medical Separation process.
Submit to: Disability Management Service
UC Davis / UC Davis Health
MSP Contract Agreement Assists Hiring Departments by defining policies and expectations for hiring managers and senior professionals on contract.
Submit to: Local HR office
UC Davis / UC Davis Health
MSP Employee Summary of Accomplishments This form is used to evaluate the performance of Managers and Senior Professional staff at UC Davis Health.
Submit to: Completed and submitted as part of the annual performance appraisal.
UC Davis Health
MSP Physician Contract Physicians complete this contract at time of employment.
Submit to: Hiring Manager
UC Davis Health
MSP Position Description Form The official outline to support hiring departments in writing a new position description for managers and senior professionals at UC Davis Health.
Submit to: Recruitment
UC Davis Health
Near Relative Request for New Hire UC Policy defines and regulates employment relationships between near relatives. This form allows hiring departments to submit a request for a near relative hire.
Submit to: Local HR office
UC Davis / UC Davis Health
Near Relative Request for Relationship Change UC Policy regulates employment relationships between near relatives. This form allows departments to submit a request for change of relationship between employees. 
Submit to: Local HR office
UC Davis / UC Davis Health
New Employee Checklist UC Davis supervisors to complete during onboarding process.
Submit to: Share completed list with employee and keep in department files.
UC Davis
New Employee Checklist UC Davis Health supervisors to complete during onboarding process.
Submit to: Share completed list with employee and keep in department files.
UC Davis Health
Non-Financial Leave Hours Adjustment For Department personnel liaisons and payroll to submit form to adjust an employee’s leave hours.
Submit to: Payroll
UC Davis / UC Davis Health
Notice of Intent to Change Conditions of Employment Departments use this form to notify HR of changing employment conditions, HR then notifies the Union.
Submit to: ELR Department
UC Davis / UC Davis Health
OnBase Form Complete to record a leave of absence.
Submit to: Shared Services Organization, UC Davis Health Records Unit
UC Davis Health
Online Earnings Statement Exception Complete if you are requesting to receive a paper Direct Deposit Earnings Statement or you are cancelling a previous request for a paper Direct Deposit Statement and now want to view your statement online.
Submit to: Payroll Services Office, or fax to 530-757-8597
UC Davis / UC Davis Health
Payroll Address Change Allows employees to notify of an address change to receive paychecks and statements.
Submit to: UC Davis Health Payroll
UC Davis Health
Payroll Checks through Mail Complete to request your payroll checks to be delivered through the mail.
Submit to: UC Davis Health Payroll
UC Davis Health
PDL Certification of Health Care Provider This form provides the medical certification to support your request for PDL due to pregnancy, childbirth, or related medical condition.

Submit to: After completion by employee and health care provider; then submit to department personnel.

UC Davis / UC Davis Health
Permanent Accommodation (webform) Managers and supervisors use this form to document permanent accommodations.
Submit to: Disability Management Services
UC Davis / UC Davis Health
Personal Data (UPAY 544) Provide necessary employment information for payroll and personnel matters.
Submit to: UCOP Payroll
UC Davis / UC Davis Health
Personal Data (UPAY 544A for Union Workers) Union workers provide necessary employment information for payroll and personnel matters.
Submit to: UCOP Payroll
UC Davis / UC Davis Health
Position Closure Proposal Complete form to initiate an indefinite position closure proposal.
Submit to: ELR Department
UC Davis Health
Position Closure Special Skills Addendum Because position closure occurs in reverse seniority order, less senior employees inform departments of special skills that may prevent layoff.
Submit to: Compensation/Classification
UC Davis Health
Position Description - How to Write This form is for Managers, Supervisors & their administrative staff and gives specific directions for completing a position description form and explains details of the approval process when recruiting or modifying. UC Davis Health
Position Description Form The official outline for writing a new position description.
Submit to: Compensation/Classification
UC Davis Health
Position Not Covered by Social Security Fill out this form to notify an employee who is not covered by Social Security about the potential effects on future benefits.
Submit to: UCOP
UC Davis / UC Davis Health
Probationary Period - Change End Date Managers and Supervisors can complete this form to request to change an employee’s probationary period end date.
Submit to: HR Administration
UC Davis Health
Probationary Period Report Managers and Supervisors complete this PPSM form at the end of a probationary period.
Submit to: Employee Relations Consultant
UC Davis / UC Davis Health
PSS Contract Agreement (exempt) Defines policies and expectations for hiring exempt professionals and support staff on contract.
Submit to: Hiring departments complete during onboarding and submit to local HR office.
UC Davis
PSS Contract Agreement (non-exempt) Defines policies and expectations for hiring non-exempt professionals and support staff on contract.
Submit to: Hiring departments complete during onboarding and submit to local HR office.
UC Davis
Property Recovery & Access Termination Supervisors acknowledge that they have recovered University property and revoked University systems access for separating employees.
Submit to: UC Davis Health HR Records
UC Davis Health
Reasonable Accommodation Record of Action Department uses form to document reasonable accommodation cases for disabled employees.
Submit to: Disability Management Services
UC Davis / UC Davis Health
Request for Staff Records Form Complete to request the personnel records of current staff members.
Submit to: hrrecords.dist@ucdmc.ucdavis.edu
UC Davis Health
Retired Employee Approvals Form For managers looking to hire, or extend an appointment for a retired employee and outlines the specific reemployment regulations for individuals who receive a retiree benefit.
Submit to: Local HR office at time of rehire
UC Davis / UC Davis Health
Screening Criteria Grid Use to screen candidates and identify who to advance to interview.
Submit to: Recruiter
UC Davis Health
Separation Checklist  A checklist of employee and supervisor responsibilities when an employee separates.
Submit to: For employee and supervisor use only. 
UC Davis Health
Separation Checklist for Supervisors A checklist of responsibilities when a supervisor separates.
Submit to: For supervisor use only.
UC Davis Health
Skelley Protocol A Skelley hearing is a formal process that allows an employee to respond to allegations prior to disciplinary action. Use this form to preparing for and participate in a Skelley hearing. UC Davis / UC Davis Health
Staff Leave Request Staff may use form to request leave using vacation, sick, comp time, leave without pay, supplemental family medical leave, or personal leave.
Submit to: Department Manager
UC Davis 
STAR Plan Nomination Form Managers and Supervisors can complete this form to nominate someone for the Star Recognition program.
Submit to: Executive Director, then to Vice Chancellor
UC Davis
Stipend Request Complete to request a stipend. 
Submit to: Compensation/Classification
UC Davis Health
Supplement to Military Pay

Active duty military personnel can receive supplemental compensation.
Submit to: UC Davis - If leave is managed by a Shared Services team, please send to the appropriate office otherwise, please provide to your supervisor.
UC Davis Health - submit to: hs-hrrecords@ucdavis.edu

UC Davis / UC Davis Health
Telephone Reference Checklist Use this form to help conduct a pre-hire reference check.
Submit to: Keep completed form with candidate's application packet.
UC Davis / UC Davis Health
Temporary Accommodation (webform) Managers and supervisors use this form to document temporary accommodations.
Submit to: Disability Management Services
UC Davis / UC Davis Health
TES Assignment Request Departments complete this form to request temporary employment services (TES).
Submit to: Temporary Employee Services
UC Davis / UC Davis Health
UAW Local 2865 Membership Election Form New ASE employees fill out this form if they want to join the UAW union.
Submit to: ELR Department
UC Davis / UC Davis Health
UBEN 109 Notice to UC of a COBRA Qualifying Event Use this form to notify the UC of the occurrence of a qualifying event that results in the involuntary loss of eligibility for coverage under the UC group insurance plans. UC Davis /
UC Davis Health
UBEN 109A Notice of Employee COBRA Qualifying Event Department personnel may use this form to notify the Benefits Office of the occurrence of a non-separating qualifying event that results in the involuntary loss of eligibility for coverage under the UC group insurance plans. UC Davis /
UC Davis Health
UBEN 116 Designation of Beneficiary-Employees Current employees may use the At Your Service Online website to name or change beneficiary(ies) for death benefits from the UC-sponsored retirement/savings and insurance plans in which you are enrolled (other than 403(b) Fidelity and Calvert mutual fund accounts). If unable to use the web, the employee may complete this form. (Submit form to UC/HR Benefits address on form.) UC Davis /
UC Davis Health
UBEN 119 Expanded Dependent Life and AD&D Insurance Designation of Alternate Beneficiary You are automatically the beneficiary if a family member who is covered under your Expanded Dependent Life and/or Accidental Death and Dismemberment (AD&D) insurance plans dies. However, if you want someone else to receive benefits if a covered family member dies, complete this form. (Submit form to UC/HR Benefits address on form.) UC Davis /
UC Davis Health
UBEN 132 UC Retirement Plan Service Credit Verification Request Use this form for service credit adjustments that do not require payment or to correct incomplete or incorrect data that could affect your UCRP benefits (UCRP service credit, UCRP entry date, or your birthdate). (Submit form and records to UCOP address on form.) UC Davis /
UC Davis Health
UC Oath of Allegiance & Patent Acknowledgement All new employees fill out form before first day of work.
Submit to: Onboarding Coordinator
UC Davis / UC Davis Health
UCRP Reemployment Notification To be completed by retirees who receive monthly retirement income and are reemployed in a senior management or staff position.
Submit to: Onboarding coordinator
UC Davis / UC Davis Health
UCRS 419 Statement Concerning Your Employment in a University Position Not Covered by Social Security This form explains how not being subject to Social Security may affect future Social Security benefits to which the individual may become entitled. This form complies with the Social Security Protection Act. (Submit form to UC HR/Benefits address on form.) UC Davis /
UC Davis Health
Union Job Steward Grievance-Related Release Time Request Union designated employee representative fills out form to request paid release time for grievance-related activities.
Submit to: Employee's Supervisor
UC Davis /
UC Davis Health
UPAY 850 Enrollment, Change, Cancellation or Opt-Out Use this form to enroll in, change, cancel, or opt out of insurance plans for yourself and/or your eligible family members. (Submit form to Employee Benefits.) UC Davis /
UC Davis Health
Verification of Licensure or Certification Complete this form to verify that an employee has a current license or certificate required for their job.
Submit to: UC Davis Health HR Records
UC Davis Health
Verification of Previous Employment Complete this form to request verification of previous UC, CSU, or State of CA employment.
Submit to: Payroll
UC Davis
Violation of Non-Smoking Policy Letter Template This template gives management an idea of how to address an employee who is violating the University's non-smoking policy. UC Davis Health
W4 - Employee's Withholding Allowance Certificate Used by employers to determine the correct amount of tax withholding to deduct from employees' wages.
Submit to: Payroll
UC Davis / UC Davis Health
Worker’s Compensation Claim Form (DWC 1) & Notice of Potential Eligibility Complete this form to file a workers’ compensation claim with your employer.
Submit to: Workers' Compensation, Fax: 916-734-2484
UC Davis Health
Workers' Compensation Departmental Injury/Illness Worksheet Complete this form to file a workers’ compensation claim with your employer.
Submit to: Workers' Compensation, Fax: 916-734-2484
UC Davis Health
Years of Service Award Procedure Each department honors its own employees with years of service awards, this checklist provides them with an easy to read instructions. UC Davis