Human Resources (HR)


Standard Operating Procedures


Retirement Extended Short-Term Disability

Original Effective Date:


Revised Effective Date:






  1. Guidelines, instructions and forms are available on pages 159-181, in the  Retirement Employer Manual.



  1. Complete a Form DIP-4, “Application for Long-Term or Extended Short-Term Disability Benefits” approximately 90 days prior to the conclusion of the short-term disability period.  A sample form DIP-4 is available on page 180-181 in the  Retirement Employer Manual.


  1. Form DIP-4 should be completed by the employee or legal representative, signed, and notarized.


  1. HR should complete the employer certification section of the form.


  1. The following forms must be furnished with the Form DIP-4 or as soon as possible thereafter:

Form DIP-1, “Application for Short-Term Disability Benefits”

Form DIP-E1, “Employer Master Worksheet for Determining Eligibility for Short-Term Benefits”

Form 7A, “Medical Report”

Job Description

Ret-170, “Authorization Agreement for Direct Deposit”

Ret-HM, “State Comprehensive Major Medical Plan “Retired Group Enrollment/Change Application” (NOTE: This form should be filed only if the employee has at least five years of retirement membership service earned as a teacher or State employee.)


  1. Maintain copies for file and send originals with a cover letter to the Department of State Treasurer, Retirement Systems Division, 325 North Salisbury Street, Raleigh, North Carolina  27603-1385.