Human Resources Downloadable Forms

Most forms on this page are provided here, for downloading, in Adobe's PDF format, for which you will need Adobe's Acrobat Reader program to read and print. If you don't have the latest copy of Acrobat Reader installed on your computer, Adobe makes the program available as a free download.

Human Resources Forms

• Beneficiary Designation (Retired Employee Death Benefit)
• Beneficiary Form (Group Term Life Insurance and College Travel Accident Insurance)
• Discoverer Access Request Form
• Employee Information Form (including Direct Deposit and W-4VT forms)
• Family Medical Leave Application
• Family Medical Leave Medical Certification Form
• Fitness Reimbursement Form
• Fitness Reimbursement Program Log Card
• Leave (Unpaid)
• Performance Evaluation Forms
  • Employee Performance Evaluation and Development Plan (Customizable Form):
    • Employee Performance Evaluation and Development Plan Form (PDF)
    • Employee Performance Evaluation and Development Plan Form (Word)
  • Optional Alternative to the Employee Performance Evaluation and Development Plan (Simple Performance Criteria Form):
    • Employee Performance Evaluation and Development Plan Form (PDF)
    • Employee Performance Evaluation and Development Plan Form (Word)
  • Forms for Departments Using the Dartmouth@Work Process:
    • Dartmouth@Work Work Plan and Development Plan (PDF)
    • Dartmouth@Work Work Plan and Development Plan (Word)
    • Dartmouth@Work Performance Evaluation (PDF)
    • Dartmouth@Work Performance Evaluation (Word)
• Quit Smoking Reimbursement Form 
• Retirement Elections
• Short-Term Disability Medical Certification Form
• Short-Term Disability Procedures and Forms for Exempt Employees
• Short-Term Disability Procedures and Forms for Nonexempt Employees
• Statement of Health Form
• Status Change Form
• Tuition Benefits Forms
  • Employee Status Verification Form for Grant-in-Aid Benefits 
  • Graduate Tuition Benefits Form
  • Tuition Assistance Request

Payroll Authorization Forms are available on the Payroll Forms website.

Federal Forms

• I-9 Form

Provider Forms

The following forms are available via links to the providers' Web sites. Navigation instructions are listed below.

• Beneficiary, Designation of (Calvert) (PDF Form)
• Beneficiary, Designation of (Fidelity Investments)
  • In the drop-down menu under "Quick Links", highlight "401(a)(k) Beneficiary".
  • Click on "Display".
• Beneficiary, Designation of (TIAA-CREF)
  • Scroll down to "Beneficiary Designation Forms" on the left.
  • Click on "select a form" and highlight "Beneficiary Designation, RA, GRA, SRA, GSRA, IRA, TPA, Savings & Inv. Keogh contracts".
• Dental
  • Northeast Delta Dental Claim Form (PDF Form) 
• Incapacitated Dependent Form (Anthem) (PDF Form)
• International Claim Form (Anthem) (PDF Form)
• Prescription Drug Claim Form (Anthem) (PDF Form)
• Reimbursement Account/Flexible Spending Account (Crosby Benefit Systems)
  • Crosby Benefit Systems Web site
  • Dependent Care Reimbursement Request Form (PDF Form)
  • Flex Debit Card Form (PDF Form)
  • Medical Care Reimbursement Request Form (PDF Form)
  • Procedure for Obtaining Reimbursement (PDF)
• Subscriber Claim Form (Anthem) (PDF Form)

Human Resources

• About Us
• News
• Benefits
• Compensation and Position Classification
• Employment
• Forms
• Professional Development

Quick Links

• After Hours
• ArtWorks
• Holidays
• Jobs
• Weather Policy
• Winter Break
• Working @ Dartmouth (HR Newsletter)

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