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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

Adjunct Employment Packet 
Temporary Employment Packet
Employee Information Form
PeopleAdmin User Guide
Family Medical Leave/Medical Leave of Absence Excuse/Release to Work
Medical Certification for Major Medical Leave
Family Medical Leave/Medical Leave of Absence
Excuse/Release to Work
Request for Leave
Staff Leave Request Form
Application for Leave of Absence Without Pay
Teacher Absence Request
Personal/Major Medical Leave Form
Tuition Remission Forms

Application for Employee Tuition Remission Form

Application for Dependent Child Tuition Remission Form
Application for Spouse Scholarship Form
Tuition Remission Drop Course Form
Mississippi Delta Community College Faculty/Staff Scholarship Form
Mississippi Delta Community College Dependent Student Scholarship Form
Hinds Community College Faculty/Staff Scholarship Form
Human Resource Forms

Americans with Disabilities Act Form

Employee Information Form
Change of Address Form
Compensatory Time Record
Direct Deposit Form
Faculty Pay Distribution Agreement
Monthly Time Record/Sheet
Outside Employment Form
Reference Check Release From
Reference Checking Form
Selective Service Form
Staff Evaluation Form
Hourly Performance Evaluation Form

State of Mississippi New Hire Reporting Form

Termination/Clearance Form

Textbook Scholarship Program Application

Veteran Status Form

Tax Forms
Federal Tax Form
State Tax Form
Immigration and Naturalization
I-9 Employment Verification Eligibility (Fill-in format)
Workman’s Compensation
Workers’ Compensation First Report of Injury (Fill-in format)
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
Catamaran RX Direct Member Reimbursement Form
Catamaran RX Order Form for Mail Service Pharmacy, Fax Order
Catamaran RX New Prescription Fax Form
Catamaran RX Health, Allergy & Medication Questionnaire (HMQ)
State of Mississippi Life Insurance Forms
State of MS Life Insurance Enrollment and Change Request Form
Public Employees’ Retirement System Forms
PERS Enrollment Form
PERS Beneficiary Nomination Form
PERS Change of Information
PERS Certification/Acknowledgement of Reemployment Form
Noncovered Acknowledgement Form
Application for Refund of Accumulated Contributions to Member
Pre-Application for Service Retirement Benefits

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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