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Kansas State University

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Technical Support for Forms:
Kathy Kugle (785) 532-1885
or email kkugle@ksu.edu

Forms

Division of Human Resources
Kansas State University
103 Edwards Hall
Manhattan, KS 66506-4801
785-532-6277
785-532-6095 (fax)
8 a.m. - 5 p.m. (CST)
Contact HR

Unclassified Faculty and Professional Staff Forms

Refer to unclassified transactions for personnel and payroll forms. Refer to summary of benefits for unclassified faculty and staff for benefits forms.

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Alphabetical List of Unclassified Faculty & Professional Staff Forms
FORMS by NameDatedInstructions
or Information		 Versions
Accident/Injury Report (PER-17) (Workers' Compensation) 07/2009 PPM 4820.100 RTF Word PDF  
Additional Pay 01/2007 Faculty Awards
PPM 4650.110		 RTF Word PDF 
Additional Pay Checklist #1 4/2001 Faculty Awards
PPM 4650.110		 RTF Word PDF 
Additional Pay Checklist #2 04/2005 Faculty Awards
PPM 4650.110		 RTF Word PDF 
Administrative Leave Reporting 6/2003 PPM 4860.20 RTF Word PDF 
Affiliated Person or Emeritus Faculty Form (PER-22) 7/2009 Included RTF Word PDF  
Agency Payroll Deduction Authorization 5/2007 Agency Payroll Deductions RTF Word PDF 
Agreement of Understanding for Overlapping Appointment (PER-28) 10/2004 Military Service Policy RTF Word PDF 
Agreement for Reimbursement of Moving Expenses(DA-22) 11/1998 Moving Expenses RTF Word PDF 
Application for Tuition Assistance 2009/2010       PDF 
Appointment Form (PER-38) 09/2008 4650.090 RTF Word PDF 
Authorization to Release Information 10/2004 PPM 4010 RTF Word PDF 
Background Check Request Form (PER-59)10/2008Background ChecksRTF WordPDF 
Beneficiary Designation (KPERS-7/99) 07/2006 PPM 4820.60    PDF 
Change or Separation Form (PER-39) 12/2006 Unclassified RTF Word PDF 
Conflict of Interest Form   Conflict of Interest Policy      Online
Designation of Beneficiary (KPERS-7/99) 07/2006 PPM 4820.60    PDF 
Direct Deposit of Employee Pay (PER-58) 12/2007 Instructions
Information		 RTF Word PDF 
Documentation of Service for Immediate Participation in Regents Retirement Program (PER-33) 01/2007 PPM 4810.20 RTF Word PDF 
Educational Authorization Form (PER-25) 5/1998 PPM 4870.20 RTF Word PDF 
Emeritus Faculty or KSU Affiliated Employee Form (PER-22) 7/2009 Included RTF Word PDF 
Employee Performance Review System-
Employee Performance Review (PER-47)		 03/2006 Instructions
Presentation in PPT
Supervisor's Guide - Action Steps (PDF)
Training		 RTF Word PDF 
Employee Performance Review System-
Employee's Annual Report of Activities (PER-48)		 09/2004 Instructions
Presentation in PPT
Supervisor's Guide - Action Steps (PDF)
Training		 RTF Word PDF 
Employee Peformance Review System-
Professional Development and Growth Plan (PER-49)		 09/2004 Instructions
Presentation in PPT
Supervisor's Guide - Action Steps (PDF)
Training		 RTF Word PDF 
Employee Performance Review System-
Performance on Goals and Projects (PER-50)		 09/2004 Instructions
Presentation in PPT
Supervisor's Guide - Action Steps (PDF)
Training		 RTF Word PDF 
Employee Separation Checklist (PER-24) 02/2008 Classified Separations
Unclassified Separations
PPM 4950		 RTF Word PDF 
Employment Eligibility Verification (I-9) 08/2009 Instructions    PDF 
Exit Interview Letter at Resignation 06/2007 PPM 4950     PDF 
Exit Interview Letter at Retirement 06/2007 PPM 4950     PDF 
Faculty and GTA Spoken English Competency Assessment Sheet (PER-20) 09/2009 4650.075 RTF Word PDF 
Flexible Spending Claim Form 2010 Flexible Spending Accounts     PDF
Flexible Spending Account Direct Deposit/E-Mail Notification Form   Flexible Spending Accounts   Word   
FMLA Certification of Health Care Provider for Employee's Serious Health Condition   FMLA Dept. of Labor     PDF 
FMLA Certification of Health Care Provider for Family Member's Serious Health Condition   FMLA Dept. of Labor     PDF 
FMLA Notice of Eligibility and Rights & Responsibilities   FMLA Dept. of Labor     PDF 
FMLA Designation Notice   FMLA Dept. of Labor     PDF 
FMLA Certification of Qualifying Exigency For Military Family Leave   FMLA Dept. of Labor     PDF 
FMLA Certification for Serious Injury or Illness of Covered Servicemember -- for Military Family Leave   FMLA Dept. of Labor     PDF 
KSU Foreign National Tax Information Form (PER-15) 07/2007 Visa Classifications RTF Word PDF 
Health Care Selection Form 06/2003 Health Insurance     PDF  
Health Insurance Affidavit of Common Law Marriage and Request for Enrollment of Common Law Spouse 08/2009 Health Insurance     PDF  
Health Insurance Application for Coverage of Handicapped Dependent Child 02/2008 Health Insurance     PDF  
Health Insurance Communication Form 08/2009 Health Insurance     PDF 
Health Insurance Dependent Grandchild Affidavit 07/2009 Health Insurance     PDF  
HIPAA- Authorization Form for Release of Medical Information 03/2008 Health Insurance     PDF  
Health Savings Account Enrollment & Change Form 08/2009 Health Insurance     PDF  
HealthyKIDS Application   Information(pdf)      Online
HRIS/PeopleSoft Access Form   Instructions (pdf)
HRIS Roles		 RTF Word PDF 
HRIS Problem Investigation Request Fax Form 11/1996   RTF Word PDF 
Intellectual Property Agreement   Information RTF Word PDF  
Investment Agreement - Mandatory Retirement Plan (Kansas Board of Regents) (PER-13) 01/2007 PPM 4810.20 RTF Word PDF  
Investment Agreement - Voluntary Retirement Plan(PER-19) 11/2008 PPM 4810.80 RTF Word PDF  
Kansas Board of Regents Mandatory Retirement Plan Investment Agreement (PER-13) 01/2007 PPM 4810.20 RTF Word PDF  
Kansas Board of Regents Voluntary Retirement Plan Investment Agreement (PER-19) 11/2008 PPM 4810.80 RTF Word PDF  
Kansas Employee's Withholding Allowance Certificate (K-4) 09/2007 Information     PDF  
Learning Quest Direct Investment Form Information    PDF 
Learning Quest Payroll Deduction Change Form  Information    PDF 
Leave Balance Correction Sheet (PER-9) 5/2001 Information RTF Word PDF 
Leave Record 05/2009
for FY 2010		 Instructions RTF Word PDF Excel
Leave Request-Salaried (Exempt) Faculty and Staff   Instructions      Online
Leave-Sabbatical Leave Application Form   Guidelines      Online
Life Insurance Beneficiary Designation Form (TEA) 07/2001 Included
TEA Life Insurance		     PDF  
Life Insurance Enrollment Form (TEA)   TEA Life Insurance     PDF 
Life Insurance Request to Change or Cancel Insurance Policy Form (TEA)   TEA Life Insurance     PDF  
Life Insurance Statement of Health (TEA)   TEA Life Insurance    PDF 
Mid Year Base Salary Increase Form (PER-46) 12/2003 Included RTF Word PDF 
Mileage Reimbursement Form (Workers' Compensation)   Information RTF Word PDF  
New Course Data Sheet 12/2008 Instructions (PDF) RTF Word PDF 
New Employee Orientation Forms Checklist 11/2001 PPM 4070 RTF Word PDF  
9 Month Unclassified Summer Transactions (PER-45) 04/2008 Instructions RTF Word PDF 
Non-Resident Alien Forms   Non-Resident Alien Employment       
Notification of Retirement (PER-37) 6/2009 PPM 4810 RTF Word PDF  
Optional Group Life Enrollment Form   Optional Life     PDF 
Optional Group Life Reduction/Cancellation Form 09/2003 Optional Life     PDF 
Orientation Forms Checklist 11/2001 PPM 4070 RTF Word PDF  
Paycheck Stop Payment Request (DA-6P) 05/2006 Information   PDF Excel
Payroll Transfer Form (PER-44)04/2009Instructions   PDFExcel
Performance Management Process Form NEWPerformance Management Process
Instructions		 RTF Word PDF  
Position Description (Unclassified Professional Positions) (PER-23) 10/2009 Instructions
Position Descriptions Checklist		 RTF Word PDF 
Position Data Sheet (PER-36) 02/2007 4650.140 RTF Word PDF 
Prescription Claim Form   Prescription Drug Program     PDF  
Prescription Drug Advance Purchase Certificate 03/2008 Advance Purchase Policy(pdf)     PDF  
Report/Labels Request   Reports(Ad hoc) RTF Word PDF  
Retirement Notification (PER-37) 6/2009 PPM 4810 RTF Word PDF  
Retirement Plan Investment Agreement - Mandatory (Kansas Board of Regents) (PER-13) 01/2007 PPM 4810.20 RTF Word PDF  
Retirement Plan Investment Agreement - Voluntary (Kansas Board of Regents) (PER-19) 11/2008 PPM 4810.80 RTF Word PDF  
Savings Bond Payroll Savings Authorization (PER-14) 01/2007 U.S. Savings Bonds RTF Word PDF  
Shared Leave Donation Form 8/2001 Classified PPM 4860.140
Unclassified PPM 4865.140		 RTF Word PDF  
Shared Leave Request Form 10/2007 Classified PPM 4860.140
Unclassified PPM 4865.140		 RTF Word PDF  
Substance Abuse Policy Affirmation Form 5/2007 Information RTF Word PDF  
Supplemental Pay Form (PER-8)     RTF Word PDF  
Tax Clearance Information Form for Candidates and New Hires (DA-2004a) 05/2004 Information     PDF  
TEA Life Beneficiary Designation Form 07/2001 Included
TEA Life Insurance		     PDF  
TEA Life Insurance Enrollment Form   TEA Life Insurance     PDF  
TEA Life Insurance Request to Change or Cancel Insurance Policy Form   TEA Life Insurance     PDF  
TEA Life Insurance Statement of Health   TEA Life Insurance     PDF  
Tuition Assistance Application 2009/2010       PDF 
U.S. Savings Bond Payroll Savings Authorization (PER-14) 01/2007 U.S. Savings Bond RTF Word PDF  
Workers' Compensation Accident/Injury Report (PER-17) 07/2009 PPM 4820.100 RTF Word PDF  
Workers' Compensation Mileage Reimbursement Form   Information RTF Word PDF  
W-4 Employee's Withholding Allowance Certificate
OR Update online in Employee Self Service		 2009 Included
Information		     PDF 
Withholding form
Kansas Employee's Withholding Allowance Certificate (K-4)		 09/2007 Information     PDF  
W-5 Earned Income Credit 2009 Included
Information		    PDF 
W-9 Request for Taxpayer Identification Number and Certification 10/2007 Included    PDF