CalHR Forms

Affordable Care Act (ACA)

• Affordable Care Act (ACA) Notification Checklist – CalHR 782

Annual Leave

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

Arduous Work Pay Requests

• Arduous Work Pay Request Form – CalHR 777

Bicycle Commuter Program

• Bicycle Commuter Program Quarterly Self-Certification – CalHR 873

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

FlexElect

For all other employees.

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

CEA and Exempt Appointees – forms for Personnel Offices

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

Confidential Designation Request

• Confidential Designation Request Form – CalHR 124

Criminal Record Supplemental Questionnaire

• Criminal Record Supplemental Questionnaire

Dental

• Automated Dental Plan Enrollment Authorization – STD 692 (redirect to Benefits Calculator)
• Dental Plan Direct Payment Authorization – STD 696
• Affidavit of Parent-Child Relationship – CalHR 025
• Affidavit for Domestic Partners Being Claimed as Economic Dependents – CalHR 680

Dental COBRA Forms

• COBRA Calendar
• COBRA Election Form – CalHR 767
• COBRA administrators can find Word versions of COBRA forms on HR Net.

Delegation

• CEA Position Request – CalHR 881

Dependent Re-Verification

• Dependent Eligibility Checklist – CalHR 781
• Dependent Re-Verification (DRV) Appeals Intake Form – CalHR 277

Duty Statement

In order to access the Duty Statement template/sample, click the link, save the form to your computer, and open the form via Adobe Acrobat or Adobe Acrobat Reader. If you need assistance, contact PMD@calhr.ca.gov.

• Duty Statement Template – CalHR 874
• Sample Duty Statement Template – CalHR 874 Sample

EEO Questionnaire

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

Employee Suggestion Program

For Employees/Suggesters

• Employee Suggestion Form – STD 645

For Evaluators

• Employee Suggestion Evaluation Report – STD 645A

Employee Wellness

• Healthier U Branding Policy and Approval – CalHR 145

Examination/Employment Application – STD 678

• Examination/Employment Application – STD 678
• Minimum Qualifications Determination Tool – CalHR 511B

Family and Medical Leave Act (FMLA)

• Notice of Eligibility and Rights and Responsibilities – CalHR 752
• Designation Notice – CalHR 753

FlexElect Reimbursement Accounts

• Reimbursement Account Enrollment Authorization – STD 701R
• Premium Only Plan Request for Disenrollment – CalHR 006
• Flex Elect Reimbursement Claim Form – CalHR 351
• Letter of Medical Necessity – 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.

Group Legal Services Insurance Plan

• Group Legal Enrollment Authorization Form for Actives including full-time, part-time, and direct pay departments, Form #200849
• Group Legal Enrollment Authorization Form for Retirees, Form #200686

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 Campaign Service Qualification Flowchart
• 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 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

Leave Management

• Leave Activity and Correction Certification – CalHR 139
• Leave Reduction Plan – CalHR 138
• 2021 Department Certification of Funding and Participation – Excluded Employee Leave Buy-Back Program – CalHR 749
• 2021 Department Certification of Funding and Participation – Vacation/Annual Leave Cash Out Program – CalHR 878

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 – CalHR 601

Partial Service Retirement

• Partial Service Retirement Application – CalHR 062

Pre-tax Parking

• Pre-Tax Parking/Third-Party Administrator/Reimbursable Account Claim – CalHR 681
• Account Enrollment Form – CalHR 682

Retired Annuitant Certification

• Retired Annuitant Self-Certification – CalHR 715

Retirement Designation Request

• • State Safety Retirement Determination Questionnaire – CalHR 169
  • Peace Officer/Firefighter (PO/FF) Retirement Determination Questionnaire – CalHR 170

Savings Plus

• Transfer Future Leave Accruals to Savings Plus – CalHR 271
• Financial Statements with Independent Auditor’s Report- Year Ending December 31, 2023
• Financial Statements with Independent Auditor’s Report- Year Ending December 31, 2022

Seniority

• Final Seniority Score Package – CalHR 700

State-owned Housing

• State-owned Housing Inspector Review – CalHR 165

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

Transfer Determination

• Transfer Eligibility Worksheet – CalHR 880

Veterans’ Preference

• Veterans’ Preference for Examinations – CalHR 1093
• Veterans’ Preference – Provisional Transfer Waiver – CalHR 1094

Vision Benefits

• Vision Plan Enrollment Authorization – STD 700
• Vision Plan Direct Payment Authorization – STD 703
• Dependent Eligibility Verification Checklist – CalHR 781

Vision COBRA Forms

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

Withhold

• Minimum Qualifications Withhold Determination Worksheet – CalHR 272
• For Cause Withhold Determination Worksheet – CalHR 267

Workers’ Compensation

• Industrial Disability Leave With Supplementation Benefits Information and Option Selection – STD 618S

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