All Forms

Most of these forms are in Portable Document Format (PDF) with fields to be filled out on-line using Adobe Acrobat Reader version 7.0 or later. These PDF forms should then be printed using the printer icon near the upper-left corner of the form. Some of these PDF forms can be saved when completed. but your PC must have Adobe Reader 7.0 or higher installed.

• Benefits
  • UVa Health Plans
    • Authorization to Disclose Protected Health Information (PDF)
    • Authorization to Disclose Protected Health Information to Family Member or Other Person (PDF)
    • COBRA 2013 Eligibility and Enrollment for UVA Health Plan and Davis Vision
    • COBRA 2012 Eligibility and Enrollment for UVa health Plan and Davis Vision (PDF)
    • Catamaran Mail Order Form (PDF)
    • Catamaran Prior Authorization (PDF)
    • Catamaran Reimbursement Form (PDF)
    • Dental Claim Form (PDF)
    • Housestaff Medical Enrollment Form (PDF)
    • Aetna Medical Claim Form (PDF)
    • Southern Health Medical Claim Form (PDF)
    • Mid-Year Qualifying Event Affidavit (PDF)
    • Foreign Country Enrollment Form (PDF)
    • UVa Health Plan Enrollment Form Medical Center Employees (PDF)
    • UVa Health Plan Enrollment Academic Employees—Click on Benefits@ above
    • Postdoc and Research Associate Medical Enrollment Form (PDF)
    • Southern Health Certificate of Coverage (PDF)
    • Medicare Part D Notice (PDF)
    • Privacy Notice (PDF)
  • Vision Insurance
    • Davis Vision Plan Enrollment Form (PDF)
    • Davis Vision Claim Form (PDF)
  • Flexible Spending Accounts
    • FSA Claim Form (PDF)
    • FSA Status Change Form (PDF)
  • Life and AD&D Insurance
    • Housestaff - Guardian Life Insurance Enrollment Form (PDF)
    • Medical Center - Prudential Life Insurance Enrollment Form (PDF)
    • Medical Center - Prudential Life Insurance Beneficiary Designation (PDF)
    • Medical Center - Prudential Life Insurance Evidence of Insurability - Long Form (PDF)
    • Medical Center Accidental Death and Dismemberment Beneficiary form (PDF)
    • VRS - Minnesota Life Optional Life Enrollment Form (EXTERNAL)
    • VRS - Minnesota Life Optional Life Change Form (EXTERNAL)
    • VRS - Minnesota Life Beneficiary Change Form (EXTERNAL)
    • VRS - Minnesota Life Evidence of Insurability (EXTERNAL)
    • VRS - Minnesota Life Conversion Form (EXTERNAL)
    • The Standard Life Enrollment/Change (PDF)
    • The Standard Medical Statement (PDF)
    • The Standard Conversion Form (PDF)
    • CIGNA AD&D Insurance Application (PDF)
    • CIGNA AD&D Beneficiary Form (PDF)
  • Medical Leave
    • Family Medical Leave (FMLA) Form (PDF)
  • VRS Forms
    • VRS Forms Web Page (EXTERNAL)
  • ORP, MCRP, TDSP and Cash Match
    • TDSP Authorization (Academic) (EXTERNAL)
    • TDSP Authorization (Med Center) (EXTERNAL)
    • 457 Enrollment Form (PDF)
    • 457 Payroll Change Form (PDF)
    • Fidelity Enrollment, Fund and Performance Information
    • Fidelity 401a Beneficiary form (PDF)
    • Fidelity 401a/403b Combination Beneficiary Form (PDF)
    • TIAA-CREF Enrollment, Fund and Performance Information
  • Medex Forms
    • Medex Travel Assistance Enrollment (PDF)
  • Workers’ Compensation Forms
    • Accident Report (PDF)
    • Employee Checklist for Workers’ Compensation (PDF)
    • Workers’ Compensation Panel
• Compliance and Immigration
  • Selective Service Form
  • I-9 Forms - ONLY FOR REMOTE USE
    • I-9 (PDF)
    • I9 Remote Notary Form (PDF)
  • Immigration Forms
    • Non-Immigrant Visa Forms
    • PERM (Labor Certification) Forms
    • Outstanding Professor/Researcher Forms
• Compensation Management
  • Earnings Element Request (PDF)
  • Pay Action Request (PDF)
  • Position Action Form (PDF)
  • Position Action Appeal (DOC)
  • Recognition Award Request (PDF)
• Education Benefits
  • Education Benefits Enrollment Form (EXTERNAL)
• Employee Records
  • Faculty Salaried Personnel Hire Form (PDF)
  • Faculty Wage/Student Personnel Hire Form (PDF)
  • Name/Address Change (PDF)
  • Removal of Access Privileges (DOC)
• Essential WorkSkills Nomination Form (PDF)
• Faculty & Staff Relations
  • Acknowledgment of Restricted Classified Staff Employment (PDF)
  • Acknowledgment of Restricted University Staff Employment (PDF)
  • Conditions of Employment Acknowledgment for Classified Staff (PDF)
  • Conditions of Employment Acknowledgment for University Staff (PDF)
  • Exceptional Performance Form (PDF)
  • Fitness for Duty – Initial Observation Report (PDF)
  • Family Medical Leave (FMLA) Form (PDF)
  • Notice of Improvement Needed (PDF)
  • Outstanding Contributors Award Nomination (PDF)
  • Written Notice Form (DOC)
• Leave
  • Emergency & Disaster Leave Form (PDF)
  • Ill Health Certification (PDF)
  • Leave Sharing Donor Application (PDF)
  • Leave Sharing Recipient Application (PDF)
  • Request for Overtime Leave Payment (PDF)
  • Family Medical Leave (FMLA) Form (PDF)
• Payroll
  • Direct Deposit Enrollment (PDF)
  • Moving Agreement (Revised Oct 2011) (PDF)
  • Post-Doctoral Fellow Direct Deposit Form (PDF)
  • Time Management Form (PDF)
  • Time Management Form - Shift Work (PDF)
  • VA-4 Form (PDF)
  • W-4 and VA-4 Taxes (PDF)
• Performance Management
  • Exceptional Performance Form (PDF)
  • Exceptional Performance Form (DOC)
  • Notice of Improvement Needed (PDF)
  • Probationary Progress Review/Extension/Completion Form (PDF)
• Recruitment and Staffing
  • Departmental Orientation Checklist (PDF)
  • Dual Employment Request (DOC)
  • Executive Staff Offer Letter Template (PDF)
  • Reassignment Request (PDF)
  • Request for Exemption from Hiring Freeze (PDF)