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.

FORM	Format

Human Resource Forms
The Employment Action Form replaces the Recommendation and Authorization Form, Change of Status Form and the Wage and Hour Appointment/Change of Status Form
Employment Action Form
Employment Action Form Instructions


Staff Merit Evaluation Form

New! Outside Employment Form

Employment Application	PDF
Temporary Employment Packet	PDF
Employee Information Form	PDF
Direct Deposit Form	PDF

Employee Requisition Forms
Position Request Form
Position Review Process
Compensatory Time Record	Excel
Monthly Time Record/Sheet	Excel

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	html

Request for Leave
Staff Leave Request Form	html
Application for Leave of Absence Without Pay	html

Tuition Remission Forms
Application for Employee Tuition Remission Form	html
Application for Dependent Child Tuition Remission Form	html
Application for Spouse Scholarship Form	Word
Tuition Remission Drop Course Form	Word

Personal/Major Medical Leave Form	PDF
Termination/Clearance Form	html
Americans with Disabilities Act Form	html
Veteran Status Form	html
Selective Service Form	Word
Reference Checking Form	html
Reference Check Release From	html
Faculty Pay Distribution Agreement	Word
Textbook Scholarship Program Application	Word
State of Mississippi New Hire Reporting Form	Adobe

Tax Forms
Federal Tax Form	PDF
State Tax Form	PDF


Immigration and Naturalization
I-9 Employment Verification Eligibility (Fill-in format)	PDF
I-9 Employers Handbook - Instructions for completing the Form I-9	PDF

Workman's Compensation
Workers' Compensation First Report of Injury(fill-in format)	PDF

Employee Benefit Concepts
Mediflex Claim Form
Cafeteria Plan Revocation/Change Form

State of Mississippi Health Insurance Forms
S tate Health Insurance Application Form	PDF
Blue Cross Blue Shield Change of Address Form	PDF
State Health Medical Claim Form	PDF
Catalyst Rx Direct Member Reimbursement Form	PDF
Catalyst Rx Order Form for Mail Service Pharmacy, Fax Order	PDF
Walgreens Mail Service Registration and Prescription Order Form	PDF

State of Mississippi Life Insurance Forms
State of MS Life Insurance Enrollment and Change Request Form	PDF


Public Employees' Retirement System Forms
PERS Enrollment Form	PDF
PERS Beneficiary Nomination Form	PDF
PERS Change of Information	PDF
PERS Certification/Acknowledgement of Reemployment Form	PDF
Noncovered Acknowledgement Form	PDF
Application for Refund of Accumulated Contributions to Member	PDF
Pre-Application for Service Retirement Benefits	PDF

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.

This site is maintained by Lisa Giger. Send questions and comments regarding this site to lgiger@deltastate.edu

800-GO-TO-DSU
1003 W. Sunflower Road
Cleveland, MS 38733