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Benefits
Forms
Labor Relations
Search Committee
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HR Forms
To open the form needed
- click on the Form Title
Please print, complete and submit to the Human Resources Office - Somsen
204
| Title | Format | Information/Contact |
| Workers' Compensation | ||
| Supervisor Responsibilities | ||
| 1. Complete “First Report of Injury” form and “Agency Claims Investigation” form, and immediately send to Human Resources. | ||
| 2. Have employee sign “Workers’ Compensation Leave Supplement” form and “Workers’ Compensation Program Department of Employee Relations Information and Privacy Statement” form. Immediately send both forms to Human Resources. | ||
| 3. If employee requires medical care, send them to the Winona Clinic in Winona or Olmstead Medical Center in Rochester. | ||
| 4. Employee should take the “Report of Work Ability” form and “CorVel Corporation Minnesota Certified Workers’ Compensation Managed Care Plan” form to the doctor. | ||
| 5.“Report of Work Ability” form and/or doctor’s statement must be returned to Human Resources. | ||
| Forms | ||
| Complete Workers' Compensation Packet | Complete packet of forms. | |
| First Report of Injury | Must be filled out and returned to Human Resources immediately after injury. | |
| Agency Claims Investigation | Must be filled out and returned to Human Resources immediately after injury. | |
| Workers’ Compensation Program Department of Employee Relations Information and Privacy Statement | Employee should review the privacy statement. | |
| Workers’ Compensation Leave Supplement | Employee must review and sign the form to show an understanding of the impact the injury will have on the employee's pay. | |
| Notice of Enrollment in a Certified Managed Care Plan for Workers’ Compensation Injuries and Illness | Details of the Care Plan for Workers' Compensation Injuries and Illness. | |
| CorVel Corporation Minnesota Certified Workers’ Compensation Managed Care Plan | This card should be printed, carried with the employee, and shown upon admittance to the doctor along with the report of work ability form. | |
| Report of Work Ability | This should be shown upon admittance to the doctor along with the CorVel card. The Report of Work Ability and/or a doctor's statement must be returned to Human Resources in a timely manner. | |
| Complaint Forms | ||
| Complaint Form - Employees |  |
After completing the form, please turn it into Legal Affairs, Somsen 202. |
| Complaint Form - Students | |
After completing the form, please turn it into Legal Affairs, Somsen 202. |
| Health and Dental Forms | ||
| Basic Insurance Application |  |
Application for Basic Insurance Coverage for Health and Dental Insurance |
| Dependent Eligibility Forms | |
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| Dependent Change Form | |
Dependent Change Report |
| Designation of a Beneficiary | |
Life Insurance form w/ Minnesota Life |
| Employee Data Change Form | |
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| Gold Net Form | |
Prescription Drug Claim form |
| Insurance Application-Optional | |
Used when applied for optional coverage |
| Eide Bailly Reimbursement Form (MDEA/HRA/DCEA) | |
Medical/Dental or Day Care Expenses and Faculty HRA Account |
| Other Forms | ||
| Change of Address | |
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| Tuition Waiver | |
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| Tuition Matrix | |
Employee eligibility tables |
| Search Forms | ||
| Classified Request to Fill Vacancy/Search Committee | |
New Form - Combines the old Authorization and Search Committee forms! |
| Emergency Hire Request | |
Request to waive Affirmative Action hiring policy |
| MN State Employment Application | |
Basic application for employment with the State of Minnesota |
| Unclassified Recruitment Checklist | Affirmative Action Recruiting process steps outlined | |
| Unclassified Search Packet | |
Forms for conducting an IFO/ASF or Administrative search |
| Required authorization form for Candidate Reference Checks | ||
| Payroll Forms | ||
| Direct Deposit Authorization | |
Fill able format to initiate direct deposit |
| Faculty Off-Campus Class Travel Reimbursement | Excel | Note - columns J & K contain Excel formulas |
| Timesheet Classified (gold) - ONLINE VERSION |
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Council 5 & Commissioner's Plan |
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MMA, MNA, MAPE & Classified Managerial Employees | |
| Timesheet (Temporary) (pink) |
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Classified temporary employee |
| Unclassified Timesheet | Excel | MSUAASF/Faculty & Administrator |
| Selection of Deferred Compensation Option | |
Comp/vacation conversion to 457 plan |
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6-13-07 - 6-24-08 |
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Record vacation/sick leave/comp time earned and taken |
| W-4 form | |
Employee's Withholding Allowance Certificate (2005) |
| W-2 Request for Duplicate/Corrected Wage and Tax Statement | |
Fill able format |
| Retirement Forms | ||
| IRAP Forms | Refer to the plan websites for details regarding retirement forms | |
| MNDCP Application for Changing Salary Deferral | |
Application for changing salary deferral |
| MSRS Forms | Or call WSU HR Retirement Specialist -Sandy Reed at X5006 | |
| TIAA-CREF 403b Forms | Link to MNSCU section of 403b | |
| TRA Forms | Link to MN TRA website | |
| Vacation Conversion to 403b | Applicable to MNSCU administrators only | |
| Wells Fargo 403b Forms | Link to MNSCU section of 403b information | |
| Employee Resource Forms | ||
| Assignment Request Forms | |
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| Excused Absence Forms (unclassified ) | |
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| Employee Development Form - Classified | |
"Yellow" Form |
| Performance Review Forms-classified | |
"Gold" Form |
| Position Description Forms-classified | |
non- teaching positions |
| Position Description - MSUAASF | |
MSUAASF positions |
| Position Analysis Questionnaire | |
MSUAASF positions |
| Vacation Donation Form | |
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| WC-Report on Workability | |
Filled out by healthcare provider |
