CalHR Forms

Your personnel office can provide paper copies of many of these forms.

Please note:

• Some forms can't be filled out on your computer. You'll need to print them and fill them out by hand.
• Forms that can be filled out on your computer generally can't be saved. You'll fill them out on your computer and print them each time you use them.
• You can't submit these forms online or by email.
• Some forms listed below may still be branded as "DPA" forms. CalHR is updating these forms as time permits. In the meantime, continue to use the DPA forms. 

You can also get standard forms from the DGS Office of State Printing website.

To find publications, please visit our Publications page.

Annual Leave

•  Annual Leave - Sick Leave/Vacation - Election Form CalHR 875  

Arduous Work Pay Requests

• Arduous Work Pay Request Form - CalHR 777   

Cash Options

Consolidated Benefits (CoBen)

For excluded employees and eligible represented employees in bargaining units 2, 7, 8, 16, 17, 18, and 19. 

• Consolidated Benefits Cash Enrollment Election Form - STD 702  

Cash Options

For all other employees. 

• Cash Option Enrollment Authorization - STD 701C 
• CalPERS Health Benefits Enrollment Form - HBD-12  - (Navigate to form on CalPERS web site) 
• Dental Enrollment Form - STD 692   

 CEA and Exempt Appointees - forms for Personnel Offices 

• CEA Return Rights Worksheet - CalHR 769
• Exempt Return Rights Worksheet - CalHR 770 

Dental 

• Dental Plan Enrollment Authorization - STD 692
• Dental Plan Direct Payment Authorization - STD 696
• Affidavit for Economic Dependent Children - CalHR 025 
• Affidavit for Domestic Partners or Same-Sex Spouses Being Claimed as Economic Dependents - CalHR 680 

Dental COBRA Forms 

• COBRA Election Form - CalHR 767
• COBRA Calendar

COBRA administrators can find Word versions of COBRA forms on HR Net.  

Employee Suggestion Program

For Employees/Suggesters

• Employee Suggestion Form - STD 645

For Evaluators

• Employee Suggestion Evaluation Report - STD 645A   

EEO Questionnaire  

• State Employee Race/Ethnicity Questionnaire for New Hires and Rehires -CalHR 1070 

Family and Medical Leave Act (FMLA) 

• "Notice of Eligibility and Rights and Responsibilities" (CalHR 752)
• "Designation Notice" (CalHR 753)
• "Certification of Health Care Provider for Employee's Serious Health Condition" (CalHR 754) - This new and improved form adds a section for essential functions of the job and adds a section for the health provider to put the actual time an employee may need intermittent leave.
• "Certification of Health Care Provider for Family Member's Serious Health Condition" (CalHR 755)
• "Certification of Qualifying Exigency for Military Family Leave" (Family and Medical Leave Act) (CalHR 756)
• "Certification for Serious Injury or Illness of Covered Servicemember for Military Caregiver Leave" (CalHR 757)

FlexElect Reimbursement Accounts 

• Reimbursement Account Enrollment Authorization - STD 701R
• FlexElect Reimbursement Claim Form - CalHR 351
• Premium Only Plan Request for Disenrollment - CalHR 006
• Letter of Medical Need - ASI
• Qualified Reservist Distribution (QRD) Request Form - CalHR 902  

Reimbursement Accounts COBRA Forms 

• COBRA Election Form - CalHR 689 

COBRA administrators can find Word versions of COBRA forms on HR Net.

Grievances

• Employee Contract Grievance - STD 630
• Excluded Employee Grievance - STD 631
• Job Description Form - CalHR 651 Note: Employees filing an out-of-class grievance should complete a Job Description Form and submit it to their personnel office along with their grievance form.   

Layoff

Forms from Section 400 of the Layoff Manual 

• Prior Exempt Service Questionnaire - CalHR 004
• Verification of State Service (Outside the Executive Branch) - CalHR 039
• Military Service Information - CalHR 190
• Verification of Total State Service - CalHR 690
• Military Service Qualification Worksheet
• Recognized Military Campaigns and Armed Forces Expeditionary Medals for California Seniority Credit
• Exempt Handout for Employees  

Forms from Section 700 of the Layoff Manual 

• Layoff Plan and Request for Preliminary Seniority Scores - CalHR 009 (Word Document) Note: CalHR 009 has been replaced by the online, electronic Layoff Tool. Do not use CalHR 009 form unless you have contacted your department's assigned CalHR Layoff Consultant about your layoff and you have been directed to use it. 
• Notice of Involuntary Transfer, Demotion, or Termination - CalHR 015
• Report of Current Performance - CalHR 040  

Forms from Section 900 of the Layoff Manual 

• Establishing Reemployment Lists - CalHR 016 | Instructions  

Medal of Valor 

• Governor's State Employee Medal of Valor Special Act / Special Service Award Nomination - CalHR 012  

Merit Award 

• Superior Accomplishment Gift or Cash Award Recommendation - STD 278
• Governor's State Employee Medal of Valor Special Act / Special Service Award Nomination - CalHR 012  

 Military Leave 

• Military Leave Worksheet 
• "Certification of Qualifying Exigency for Military Family Leave" (Family and Medical Leave Act) (CalHR 756)
• "Certification for Serious Injury or Illness of Covered Servicemember for Military Caregiver Leave" (CalHR 757)  

 Negri Award 

• Nomination form  

Partial Service Retirement

• Partial Service Retirement Application - CalHR 062

Pre-tax Parking 

• Account Enrollment Form - CalHR 682
• Account Claim Form - CalHR 681  

Retired Annuitant Certification 

• Retired Annuitant Self-Certification - CalHR 715  

Seniority 

• Final Seniority Score Package - CalHR 700 - Word document  

State Restriction of Appointments 

• SROA Scantron Form
• SROA/ISWAP Worksheet

Travel, Relocation, Reimbursement 

• Travel Expense Claim - STD 262
• Hotel/Motel Transient Occupancy Tax Waiver - STD 236
• Excess Lodging Rate Approval (with Attachment ) - STD 255C
• Out-of-State Travel Approval Request - STD 257
• Out-of-State Travel Approval Request (Trip Description) - STD 257C
• Blanket Approval for Out-of-State Travel - STD 260
• Authorization to Use Private Owned Vehicle on State Business - STD 261
• Insurance Verification & Authorization to Operate Privately Owned/Rented/Leased Aircraft on State Business - STD 265   

Vision Benefits 

• Vision Plan Enrollment Authorization - STD 700
• Premier Vision Plan Enrollment Authorization - CalHR 774  
• Vision Plan Direct Payment Authorization - STD 703
• Retiree Vision Plan Deduction and Enrollment Authorization - CalHR 695
• Vision Services Plan Brochure/Enrollment Form  

Vision COBRA Forms  

• COBRA Election Form - CalHR 767

• COBRA Calendar

COBRA administrators can find Word versions of COBRA forms on HR Net. 

Workers' Compensation

Please visit our Publications page to get the Workers' Compensation Claim Kit.