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NC Department of Health and Human Services
Division of Human Resources
 
 
 
NC DHHS HR

Forms

Employee Forms

Academic Assistance external link (OSP)
Federal IRS Forms external link (IRS)
Federal Tax Withholding W4 (PDF, 224KB)
I-9 Employment Eligibility Verification external link (USCIS)
Immigration and Naturalization Form external link (USCIS)
Job Application external link (OSP)
NC Flex Forms (PDF, 98KB)
New Employee Orientation Checklist (PDF, 41KB)
Separation Forms

State Tax Withholding NC-4 external link (DOR)
State Retirement Beneficiary Designation Form (PDF, 974KB)
State Health Plan Important Forms external link (State Health Plan)
Excels Values Definitions, Roles and Key Actions (DOC, 236KB)

Work Performance Plan Forms (for FY 2011-2012)

Forms for HR Staff

Benefits

Certificate of Health Care Provider for Employee’s Serious Health Condition (Form WH-380-E) external link (US DOL)
Certificate of Health Care Provider for Family Member’s Serious Health Condition (Form WH-380-F) external link (US DOL)
Certificate of Qualifying Exigency for Military Family Leave external link (US DOL)
Certification for Serious Injury or Illness of Covered Service member for Military Family Leave external link (US DOL)
Family Medical Leave Act / Family Illness Leave Request Form (PDF, 201KB)
Voluntary Shared Leave Application (PDF, 157KB)
Voluntary Shared Leave Donation (DOC, 53KB)

Classification and Compensation

319 Employee Relationship Questionnaire (PDF, 908KB)
ADA Checklist (PDF, 115KB)
Agency Check Request (DOC, 48KB)
Analyst Notes (General) (PDF, 501KB)
Analyst Notes (Career Banding) (DOC, 96.9KB)
Analyst Notes (OSSOG) (PDF, 311KB)
Contract Approval (PDF, 111KB)
Career Banding Pay Dispute Process (PDF, 71KB)
Dual Employment external link (Instructions PDF, 84KB)
FLA Test Executive (PDF, 367KB)
FLSA Test Administrative (PDF, 358KB)
FLSA Test Professional (PDF, 259KB)
FLSA Test Creative Professional (PDF, 359KB)
FLSA Test Computer Related (PDF, 362KB)
Freeze Release (Divisions)(DOC, 162KB)
Freeze Release (Facilities) (DOC, 149KB)
In-Range Equity (PDF, 196KB)
In-Range Job Growth (PDF, 158KB)
In-Range Labor Market (PDF, 173KB)
Job Description (Career Banded) (PDF, 322KB)
Job Description (Interns) (DOC, 27KB)
Job Description (PD-OSS93) (DOC, 78KB)
Job Description (PD102r-92) (DOC, 49KB)
Mentor Pay Authorization (DOC, 59KB)
Nurse Sign On Bonus PAF (PDF, 68KB)
Nurse Weekend Option Day Memorandum (DOC, 41KB)
Nurse Weekend Option Night Memorandum (DOC, 41KB)
Overtime/On Call/Call Back Agreement (PDF, 89KB)
Position Spreadsheet (XLS, 54KB)
Program Evaluation Guide (PDF, 478KB)
Request to Add Position/Class to On-Call List (PDF, 196KB)
Retention Adjustment Worksheet (PDF, 50KB)
Retired Temporary Employees Agreement (PDF, 246KB)
Salary Decision Worksheet (Career Banding) (DOC, 64KB)
Salary Equity Analysis Worksheet (XLS, 41KB)
Salary Overpayment Collection (PDF, 110KB)
Salary Exception Worksheet (PDF, 53KB)
Secondary Employment Form (DOC, 49KB)
Sleep Policy Agreement (PDF, 86KB)
Unofficial Trainee Worksheet (PDF, 61KB)
Work Against Worksheet (PDF, 359KB)

Employee Relations

Employee Disciplinary Action Routing Form (PDF, 287KB)
Employee Grievance Filing Form (PDF, 276KB)
Performance Rating Dispute Process Complaint Filing Form (PDF, 338KB)
Proposed Dismissals, Demotions and Disciplinary Suspensions Form (PDF, 175KB)
Program Evaluation Form (PDF, 364KB)
Statement of Backpay (PDF, 261KB)

Recruitment

Applicant Selection Codes (PDF, 30KB)
Freeze Guidelines (PDF, 141KB)
Job Posting Form (PDF, 105KB)
GS 126 RIF PLAN Template (DOC, 64KB)
GS 126 RIF Worksheet (XLS, 17KB)
GS 115C RIF PLAN Template (DOC, 44KB)
GS 115C RIF Worksheet (XLS, 17KB)
Reference Check (PDF, 106KB)
Release Form (PDF, 111KB)

Safety

Applicant Consent and Acknowledgement Form (DOC, 37.5KB)
Consent and Acknowledgement for CDL (PDF, 121KB)
Consent and Acknowledgement Form for Random and Reasonable Cause (PDF, 91KB)
Criminal Record Check Consent (PDF, 83KB)
Criminal Record Check Letter (PDF, 137KB)
Criminal Record Check Request (PDF, 270KB)
Criminal Record Check Transmittal (PDF, 125KB)
Direct Care / Critical Care Request (PDF, 253KB)
Direct Care List
Critical Care List
Criminal Justice Drug Test Applicant Consent Form (PDF, 245KB)
State Employee Incentive Bonus Program Routing Form (PDF, 290KB)
State Employee Incentive Bonus Program Employee Suggestion Form (PDF, 314KB)
Statistical Report (PDF, 271KB)

Training and Development

Application For Academic Assistance external link (OSP)
Academic Assistance Annual Report (PDF, 44KB)
Continuing Education Units Application (PDF, 148KB)
Continuing Education Units Instructor Credentials Form (PDF, 141KB)
Continuing Education Units Planning Worksheet (PDF, 109KB)
Continuing Education Units Review (PDF, 86KB)
Conference Authorization (PDF, 442KB)
OSP Professional Skills Course Registration external link (OSP)
EEOI Registration (PDF, 18KB)
Extended Academic Leave Request (PDF, 44KB)
Managing Effective Performance external link (OSP)
Staff Development Report (PDF, 212KB)
Staff Development Report w/instructions (PDF, 405KB)
Training Requirements Acknowledgement (PDF, 91KB)

Worker’s Compensation

CorVel Medical Authorization and Prescription Form (DOC, 90KB)
Death Claim Notice (PDF, 244KB)
DHHS Witness Statement (PDF, 147KB)
Employee Injury Report (PDF, 152KB)
Supervisor Investigation Form (PDF, 135KB)
Leave Option Form (PDF, 164KB)
Return to Work with Restricted Duties (PDF, 302KB)
Settlement Approval Request Form (PDF, 109KB)
Statement of Charges for Travel external link (NCIC 25T)
Statement of Days Worked and Earnings of Injured Employee external link (NCIC 22)