Human Resources Forms

These documents should not be modified without consent from Human Resources

Frequently Used Forms

Direct Deposit

Dual Employment Request Form (CT-HR25)

Name/Address/Phone Change Form

W-4 CT State Tax & Federal Tax Forms

Work History Form

Tuition Waivers

Tuition Waiver Form for Unclassified Employees (AAUP, SUOAF, Management/Confidential)

Graduate-Level Educational Assistance Tax Reporting Requirements

Tuition Reimbursement - Classified Employees Only

• Tuition Reimbursement Application (CO-101)
• Tuition Reimbursement Instructions

Scholarships

• Classified Employee and/or Dependent Child Announcement Letter
• Classified Employee and/or Dependent Child Scholarship Award Guidelines
• Classified Employee Scholarship Application
• Classified Employee Dependent Child Application

For additional information on the Classified Scholarship Program, please contact Christine Derwitsch Assistant in Human Resources, (860) 832-1756.

Employment Forms

Situational Telework

• Situational Telework – Clerical

Administrative Faculty Telework

• Administrative Faculty Telework Request Form

Background Check and Authorization

• Disclosure and Consent Form
• Social Security Verification Authorization (SSA-89)
• Summary of Your Rights Under Fair Credit Reporting Act (FCRA)

Classification

• Duties Questionnaire

Faculty Forms

• AAUP Emergency Appointment

Part-Time Faculty Hiring Forms

• Part-Time/ Full-Time Faculty Appointment Form

University Assistant Appointment Forms

• University Assistant Appointment Form (2023-24) Effective 4/27/2023

Search Forms

• AAP-1 Personnel Action Request Form
• AAP-2 Affirmative Action Search Plan
• AAP-3 Authorization to Interview
• AAP-4 Recommended Candidates
• C-1 Classified Authorization to Interview
• C-2 Classified Recommended Candidates
• Temporary Appointment Form (SUOAF and Management Confidential)

Faculty Related Forms

• 10.12 - Instructional Faculty Authorization Form
• 10.12.1 - Duties with No Load Credit
• 10.13 – External Teaching Employment Form
• Dual Employment Form (CT-HR-25)
• Compliance Form for Full time Faculty for Reporting of Research or Consulting with Outside Public or Private Entity
• Faculty Consulting and Research with Private and Public Entities FAQ’s
• Procedure for Reporting of Research or Consulting with Outside Public or Private Entity
• Employee Information Sheet

Evaluation Forms

AAUP Evaluation Forms

• Teaching Faculty Evaluation & Recommendation for Renewal, Tenure & Promotion or Professional Assessment
• Coach and Non-Instructional Athletic Trainer Evaluation & Recommendation for Renewal & Promotion
• Counselor Evaluation & Recommendation for Renewal, Tenure, Promotion or Professional Assessment
• Librarian Evaluation & Recommendation for Renewal, Tenure, Promotion or Professional Assessment

Classified Employee Evaluations Forms

• Administrative Clerical
• Administrative & Residual
• Maintenance & Service
• Protective Services
• SUOAF Evaluation Form

Medical Related Forms

• Employee Request Form (FMLA-HR1)
• Employee Medical Certificate – (P33A)
• Caregiver Medical Certificate – (P33B)
• Health Enhancement Program Plan Enrollment Form - (CO-1314)
• Intent to Return to Work – (FMLA-HR3)
• Military Family Leave – Employee – Attachment
• Military Family Leave – Service Member
• Sick Leave Bank Grant Application – AAUP – Attachment
• Sick Leave Bank Grant Application – Management/Confidential - Attachment
• Sick Leave Bank Grant Application - SUOAF

For additional FMLA information contact Victoria Karwowski in Human Resources, at (860) 832-1759.

Retirement Forms

• Limited Durable Power of Attorney Pre Retirement Form (CO-1049)
• Designation of Retirement Plan Election (CO-931h)
• Designation of Retirement Plan Beneficiary (CO-999)
• Retirement Credit Purchase Request for Prior Miscellaneous Services Form
• SERS Tier IV Summary

Tier 3 and Hybrid Credit Purchase (CO-991)

Voluntary Schedule Reduction Program

• Voluntary Schedule Reduction Request Form

Workers’ Compensation

• DAS Form 207 - First Report of Injury
• DAS Form 207-1 - Incident Review Report
• WCC Form 1A - Filing Status and Exemption
• DAS Form PER-WC 211 - Concurrent Employment and Third-Party Liability
• DAS Form WC-715 - Request for Use of Accrued Leave With Workers' Compensation
• DAS Form 208 – Worker Status Report