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Human Resource Forms

Click on the desired title to access the form. The PDF format forms can be viewed and printed using the free Adobe Acrobat Reader. If you do have the reader, you may download from the link below.

Employment Action Form/One Time Payment – Revised 06/10/2014
Employment Action Form Instructions

Job Analysis Questionnaire

Job Analysis Questionnaire

 Employment Forms

Adjunct Employment Packet 
Temporary Employment Packet
Employee Information Form
Reference Check Release From
Reference Checking Form
State of Mississippi New Hire Reporting Form
Federal Tax Form
State Tax Form
I-9 Employment Verification Eligibility


PeopleAdmin User Guide

Timekeeping & Leave Forms

Monthly Time Record/Sheet
Staff Leave Request Form
Application for Leave of Absence Without Pay
Teacher Absence Request
Personal/Major Medical Leave Form
Family Medical Leave/Medical Leave of Absence

FMLA Medical Certification Form
Regular Major Medical Certification Form

Excuse/Release to Work

Scholarship Forms

Application for Employee Tuition Remission Form

Application for Dependent Child Tuition Remission Form
Application for Spouse Tuition Remission Form
Tuition Remission Drop Course Form
Community College Faculty/Staff Scholarship Form to Attend DSU
Mississippi Delta Community College Faculty/Staff Scholarship Form
Mississippi Delta Community College Dependent Student Scholarship Form
Textbook Scholarship Program Application

Human Resource Forms

Americans with Disabilities Act Form

Employee Information Form
Change of Address Form
Outside Employment Form
Direct Deposit Form
Faculty Pay Distribution Agreement
Veteran Status Form
Selective Service Form
Staff Evaluation Form
Hourly Performance Evaluation Form
 Performance Improvement Plan Form

Drug and Alcohol Testing Forms

Reasonable Suspicion Form
Prescription & Non-Prescription Drug Voluntary Disclosure Form


Southern Administrators and Benefit Consultants (Cafeteria Plan)
Request for Reimbursement
Dependent Care Receipt Form
Change of Status Form
Delta Dental Insurance
Benefit Information
Enrollment Form
State of Mississippi Health Insurance Forms
State Health Insurance Application Form
Blue Cross Blue Shield Change of Address Form
State Health Medical Claim Form
State of Mississippi Life Insurance Forms
State of MS Life Insurance Enrollment and Change Request Form
Public Employees’ Retirement System Forms
PERS Enrollment, Membership Application, Form 1
PERS Beneficiary Designation, Form 1B
PERS Change of Information, form 1C
PERS Reemployment of PERS Service Retiree, Form 4B
Non-Covered Employment Acknowledgement, Form 4A
Membership Refund Application, Form 5
Pre-Application for Service Retirement Benefits, Form 9A SRVC

Delta State University is committed to a policy of equal employment and educational opportunity. Delta State University does not discriminate on the basis of race, color, religion, national orgin, sex, age, disability, or veteran status. This policy extends to all programs and activities supported by the University.

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