Forms

A

Acknowledgment of Driver License Requirement 
Administrative Leave Extension Request 
Administrative Rule Waiver Request 
Administrative Rule Waiver Request: Extension of Eligible List 
Affidavit of State of Iowa Warrant Fraud
Affidavit of Common Law Marriage
Agreement for Recouping Education Payments
Agreement for Recouping Relocation Payments
Alternative Duty Assignment 
Alternative Duty Notice to Employee 
Appeal Board Administrative Form
Authorized Signator Form

B

Background Check Policy Template
Building Access Identification Cards

C

Calculate Market Value Differential
Calculating Mortgage Interest Differential
Calculation of Income Tax Assistance Payment
Capitol Complex Events Form
Capitol Complex Grounds/Administration Buildings Form
Certified Public Manager (CPM) Application
COBRA Notification/Election form
Commercial Driver License Supplement Application
Complaint Form, Employee
Confidential Personal Data Form

D

Delta Dental Insurance Application
Departure Survey Employee Information 
Dependent Disability Certification
Dig Application 
Direct Pay Continuation Form
Domestic Partner
Declaration of Domestic Partnership
Domestic Partner Termination 
Domestic Partnership: Cancellation of Health and Dental Coverage 
Domestic Partnership: Reenrollment in Health and Dental Insurance
Donated Leave

Donated Leave for Catastrophic Illness Application
Donated Leave for Catastrophic Illness Immediate Family Member Application
Donated Leave for Catastrophic Illness Request (for Agency HR use)
Donated Leave for a Catastrophic Illness Immediate Family Member Request (for Agency HR use)
Donated Leave Tracking
Donated Leave Tracking (Family Members)

E

Education Payments: Agreement for Recouping Education Payments 552-0707
Education Leave and/or Education Financial Assistance Application
EFT Authorization State of Iowa Vendor Use Only (Not for Employee Payroll Use) 
Emergency Procurement Justification Form 
Employee Complaint Form
Employee Grievance Form 
Employee Separation Form 
Evacuation Assistance form, Employee Request for 
Exit Information Questionnaire

F

First Report of Injury or Illness

Full-Time Student Certification Status Form 

Non-Workday Agencies - FMLA forms 
   Application and Intent to Return to Work
   Certification of Healthcare Provider for a Serious Health Condition 
   Certification of Healthcare Provider for Family Member's Serious Health Condition
   Employee Rights and Responsibilities
   Leave Retention
   Return to Work Certification

Certification of Military Family Leave
   Qualifying Exigency 
   Military Caregiver Leave of a Current Servicemember 
   Military Caregiver Leave of a Veteran

   Designation Notice 
   Notice of Eligibility and Right & Responsibilities
   Servicemember Family Leave Application

G

GAX - General Accounting Expenditure

H

Health Insurance Applications 
  Health Insurance Application: Iowa Choice or National Choice PDF

Alliance Select PDF (SPOC-covered only)

Wellmark Automatic Payment Authorization

Health Insurance - Prescription Reimbursement Claim Form 

I

IDOM Equipment/Service Justification Form

Insurance Arrears & Adjustments

Arrears Payoff Form
 

J

K

L

Layoff Plan - Contract-Covered Employees (SPOC) 
Layoff Plan - Merit-Covered Employees
Life Insurance 
    Life Insurance Claim Application (to be completed by agency)
    Beneficiary Designation 
    Beneficiary Statement (method of benefit payment) 
    Enrollment   

M

MD-Manual Disbursement Document
Military Leave Checklist for State of Iowa Employees (552-0796) 
Military Leave of Absence Request (Exceed 30 Days) (552-0797) 
Military Leave Performance/Increase (552-0799) 
Military Leave Request for Leave Dates (552-0798) 
Military Service Voluntary Written Notice of Intent Not to Return (552-0800) 
Motor Vehicle Law Conviction Notice 
Moving Company Bid Sheet

N

Non-SLIP Retirement Process Checklist

O

P

Parking Decal Application
PDS Certificate Program Enrollment Forms
    Talent Development Certificate
    Advanced Talent Development Certificate
    Leadership Capacity Building Development Certificate
    Management Development Certificate

PDS Course Registration Form
Performance Plan and Evaluation Form
Personnel Mobility Assignment Agreement
Personnel Services Pre-Contract Questionnaire
Position Description Questionnaire NOTICE (See Instructions.)
Pre-Auditor's Authorized Signator Form

Q

R

Reasonable Accommodation Request 
Request for Adaptive Google Software
Relocation: Agreement for Recouping Relocation Payments 552-0751
Relocation Expense Recap
Request for Exception to Statewide Policies
Request to Deny Peer Assistance
Request to Establish New Fund
Request for Warrant Cancellation
Request for Warrant Stop Payment/Rescind Stop
Requisition for Goods & Services Form
Retention Point Calculation Worksheet 
Retirement - Continuation of Benefits 
    Application for the Retired/Disabled Health and Dental Insurance Group  
    Wellmark Group Retiree Application (use for Iowa Choice, National Choice, Group Program F, and Group Program N) 
    Group MedicareBlue Rx - Iowa/National Choice 
    Group MedicareBlue Rx (use with Group Program F or Group Program N) 

RIC Inactive Provider Beneficiary Form 
RIC Inactive Provider/In-service Distribution Form 
RIC Unforeseeable Emergency Form

S

Safety Glasses Form and Instructions
Short Form SS-8
SLIP - Enrollment Form
SLIP - Calculation Worksheet
SLIP - Enrollment Checklist for Human Resources Associates
SLIP - Retiree Rehire Authorization
Sole Source Purchase Form
Space Allocation Form 
Special Pay/Appointment Action 
SPOC Vacation to Sick Leave Conversion 
Statement of Ownership of Principle Residence
Substitute W-9 Vendor
Summary of Internal Policies for Claims Crossing FY

T

Temporary Staffing Services Vendor Request 
TP - Travel Payment
TPN - Travel Payment Non-Reverted
TPO - Travel Payment Overpayment
TP (RELO-EXP) - Travel Payment for Relocation Expenses
TP (RELO-SUB) - Travel Payment for Relocation Subsistence
TPR - Travel Payment Reverted

U

V

Vehicle Accident Report Form
Vendor Complaint Form
Vendor Conversion Form (I/3)

W

Workers' Comp Benefit Election Form
Workers' Comp Travel Reimbursement Request
Workers' Comp Wage Statement 
Workplace Violence Report (see Complaint Form, Employee)

X

Y

Z

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