DHR Forms and Personnel Memoranda

 

Helpful Links 

Personnel Memorandum

Chancellor's Regulations

Rules and Regulations Governing Non-Pedagogical Administrative Employees

Pre-Employment Background Checks

Employee Population     Forms Notes
All titles OSPRA 103  The NYC Department of Education no longer accepts paper OSPRA 103 form. OSPRA 103 form is completed electronically via an online application system.
All titles OSPRA 104 This form is used to release fingerprint results from NYC Department of Education to NY State Education Department. Applicants must submit the completed OSPRA 104 Form via fax or in person:- Fax #: 718-935-2726- In person: Walk-in Center at 65 Court Street, Brooklyn NY

All titles

Fingerprint Referral Form The NYC Department of Education no longer accepts paper Fingerprint Referral form. This form is completed electronically via an online application system.
All titles Employment Eligibility Verification (I-9) form The NYC Department of Education no longer accepts paper I-9 form. This form is completed electronically via an online application system.
All titles Background Questionnaire Form The NYC Department of Education no longer accepts paper Background Questionnaire form. This form is completed electronically via an online application system.
All titles Conditional Offer of Employment Medical Form Some applicants are required to provide medical documentation to determine fitness prior to employment with the DOE. Applicants are notified at the time of the employment offer if this form is necessary.

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On-boarding

 

Employee Population Forms Notes

All titles                          

Chapter 68: Conflict of Interest Form  

This form must be completed by all new hires, after reviewing the Conflicts of Interest Law described in the corresponding pamphlet.

 All titles

OP-4444 - Employment Relationship with Family

This form must be completed by all new hires. Note: A new form must be submitted whenever a change or additional relationship occurs.

 H-Bank & Z-Bank

Designation of Beneficiary

This form must be completed by all new H/Z Bank administrative hires. Note: A new form must be submitted whenever there is a change to beneficiary information in relation to annual leave accruals. Completed forms should be submitted to the Administrative Employees Unit, Room 501, 65 Court Street, Brooklyn, NY 11201.

All titles Application Form for NYC DOE Photo ID Card This form must be completed in order to obtain a DOE photo ID card. Submit the completed form in person at HR Connect Walk-in Center at 65 Court Street, Room 102, Brooklyn, NY 11201.

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Personal and Tax Data Changes

Employee Population Forms Notes
All titles Personal Tax and Data Change Form This form is used to make changes to your tax withholding, make a name change, make a Social Security Number correction, or make a date of birth correction.

All titles

W-4

This form is used to update your Federal taxes, such as declaring dependents.

All titles

IT-2104

This form is used to update your NY State taxes, such as declaring dependents.

All titles

IT-2104-E

This form is used to declare tax exempt for NY State taxes.

All titles 

Withholding Certificate Affirmation

This form is used in addition to the W-4 and/or IT-2104-E when declaring exempt.This form is also used when requesting more than 10 allowances for Federal and more than 14 allowances for State. 

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Payroll and Direct Deposit

Employee Population Forms Notes
All titles Direct Deposit Form This form is used to sign up for direct deposit of your paycheck.
 All titles Stop Payment Form This form is used by payroll secretaries and timekeepers to stop a paycheck payment.
T-Bank (per session, F & Z Bank) T-Bank Stop Payment Request Form This form is used by payroll secretaries and timekeepers to stop a paycheck payment for T-Bank employees.
 All titles TransitBenefit Plans This document contains information about WageWorks.
All titles Access-A-Ride This form is used to enroll, update, or cancel Access-A-Ride Benefits.
All titles Park-And-Ride This form is used to enroll, update, or cancel Park-And-Ride Benefits.

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Loan Forgiveness

Employee Population Forms Notes
 All titles Third-party forms Please be advised that HR Connect does not fulfill Loan Forgiveness applications. This type of request should be handled at the school level. 

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Employment Verification

Employee Population Forms Notes
 All titles Employment Verification Form This form is used to request employment information for a DOE employee, such as salary and start date.
 Retirees Employment Verification For for Pension Purposes This form is used to request employment information for a DOE retiree for pension purposes.

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Health Benefits

Employee Population; Forms  Notes 
All eligible titles Use Employee Self-Service: nyc.gov/ESS Employee Self Service (ESS) is used to enroll in health benefits or to process changes to your benefits election via an online application.  For assistance with ESS, click here. If enrolling dependents, all necessary supporting documentation must be submitted. 
All eligible titles (w/ domestic partners) ERB Health Benefits Application The ERB form Health Benefits Application must be submitted for all employees who plan on enrolling a domestic partner. Employees must first enroll themselves and any dependents in ESS before sending in an ERB form for their domestic partner.  For assistance with ESS, click here.  If enrolling dependents, all necessary supporting documentation must be submitted.

All eligible titles

ESS Coversheet The ESS Coversheet should accompany any supporting documentation faxed to the Benefits office for requested changes to dependent coverage or waiver status. Health Benefits enrollments must first be submitted in ESS before sending in your supporting documentation. For assistance with ESS, click here.   
All eligible titles Young Adult Health Benefits Coverage Eligibility Certification Form Instructions, an FAQ, and certification form for enrolling a young adult dependent.
Payroll secretary Health Benefits Report Inquiry (1054) Payroll secretaries can submit a status change, claim, inquiry, or make a request for ID Cards, refunds, or deductions on behalf of an employee currently enrolled in benefits.

All eligible titles

Medical Spending Conversion Form (Plan Year 2015) The Medical Spending Conversion Health Benefits Buy-Out Waiver Program allows employees to receive an incentive payment for waiving their City health benefits. 
All eligible titles

COBRA Continuation of Coverage for Healthcare Application (and rates)

COBRA continuation of coverage can be elected by eligible persons who have lost coverage due to termination of employment or a reduction of work schedule.

Retirees ERB Health Benefits Application Retirees who elect for health benefits must submit an ERB Health Benefits Application.  If enrolling dependents, all necessary supporting documentation must be submitted. 

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Leaves

FMLA (Family and Medical Leave Act)

Employee Population Forms  Notes 
Administrative Staff and Pedagogical Staff only Request for Leave under the Family and Medical Leave Act (FMLA) form This form is used to apply leave of absence for personal illness, maternity child care, maternity disability, care of sick child/family member.

Leave Without Pay

Employee Population Forms Notes
Non-Supervisory Pedagogical Employees only Submit forms online via Self-Service Online Leave Application System (SOLAS) Non-supervisory pedagogical employees must use SOLAS to apply for all leave types except for military leaves.
Supervisory Staff (including principals, APs and EAs)  

OP 160: Leave of Absence Without Pay

OP 198 (Application for Absence due to Personal Illness-Sick Leave) and OP 198-Part 2

OP 407 (Confidential Medical Report and Medical Evaluation Form)

These forms are used to apply for personal illness, restoration of health, as well as non-medical leaves. For restoration of health leave, you must complete OP407, OP160 and OP198. For military leave, you must complete OP160-1
Administrative Staff only  

PD 6: Leave of Absence for Health Reasons

 

This form is used to apply for leave of absence for health reasons. There is no minimum service requirement for permanent employees; provisional employees must have worked a minimum of 1250 hours.
Family Paraprofessionals & Hourly Non-Competitive Employees only  

Family Paraprofessional & Hourly Non-Competitive Employee Leave Application

 

This form is used to apply for leave of absence without pay for Family Paraprofessionals and hourly Non-Competitive employees.

UFT Educational Paraprofessionals only Submit forms online via Self-Service Online Leaves Application System (SOLAS) UFT Educational Paraprofessionals must use SOLAS to apply for all leave types except military, workers comp and LODI. 
Pedagogical and Educational employees, Hourly employees, & Administrative staffs only OP 160-1: Application for Military Leave of Absence This form is used to apply for military leave of absence without pay.

Leave With Pay

Employee  Population  Forms  Notes 
Administrative Staff only Leave of Absence with Pay Recommendation Form This form is used to apply for medical leave without pay or with pay.  PD 6: Leave of Absence for Health Reasons must be attached.
Supervisory Staff (including principals, APs and EAs)  

OP 8: Application for Sabbatical and Statement by Applicant

Addendum  to Study Sabbatical application for changes in courseworkWaiver to work while on Study Sabbatical Application

This form is used by instructional staff to apply for sabbatical leave of absence.
Pedagogical and Educational employees, Hourly employees, & Administrative staffs only  OP 160-1: Application for Military Leave of Absence Extended Military Benefits Program Enrollment For (DP-2520) This form is used to apply for military leave of absence with pay. Military leave with pay is ONLY for covered operations only (i.e., Operation Enduring Freedom, Operation Iraqi Freedom, Operation Noble Eagle or operations specifically connected with Homeland Security)
Non-Attendance Leave

Employee Population    Forms  Notes 
Administrative employees only PD 19 (Application for Excuse of Absence with Pay for Administrative Employees) This form is used to apply for leave of absence with pay for administrative staff in guidance with Rule 6.8 in Rules and Regulations for Administrative Employees.
Instructional Staff (including UFT Staff) OP 201 (Application for Excuse of Absence without Pay and/or as Non-Attendance for Teachers) This form is used to apply for leave of absence without pay for instructional staff. Must be completed and signed by Principal and Superintendent.

Retirement/Terminal Leave

Employee Population  Forms                            Notes 
Instructional Staff (including CSA & UFT Staff) OP 40 Application for Retirement Leave of Absence  This form is used to apply for a terminal leave of absence – a paid leave taken up to a semester before retirement. Must be eligible for retirement and have enough CAR time available. This leave must be applied for at least 30 days prior to its commencement.
Non-supervisory H-Bank Administrative Staff (permanent, non-competitive titles and provisional titles included) Application for Terminal Leave of Absence with Pay This form is used to apply for terminal leave of absence with pay. Must be eligible for retirement. Application must be submitted at least 30 days prior to the start date of retirement.
Non-Supervisory Pedagogical Employees only Retirement Credit for Leave of Absence (OP 183) Service credit for retirement purposes may be recommended for a leave of absence without pay for restoration of Health

Borrowing/Donating Leave

Employee Population  Forms                         Notes
UFT Educational Paraprofessionals only UFT Educational Paraprofessionals - Borrowing Sick Days Application This form is used to borrow sick days for personal illness. Must be accompanied by a signed/stamped diagnostic physician’s note that states the nature of the illness.
Administrative Employees, Hourly Support Staff only Donation of Leave for Illness Form: E745, Q744, H740 This form is used to donate sick leave balance to another employee. Important: Administrative employees must fax this form to CyberShift at 718-935-2795. Hourly employees must fax this form to Payroll at 718-935-4093.
Pedagogical Staff only CAR Transfer Form - For Pedagogues This form is used to donate CAR days to another employee. For every 2 days of leave donated, the recipient receives 1 day of leave. The donor cannot have a leave balance of more than 180 days or less than 50 days.

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Medical

Employee Population    Forms Notes 
Instructional Staff only OP 407 (Confidential Medical Report and Medical Evaluation Form) This form is used to document medical report and evaluation for medical leave of absence. Important: In addition to OP407, you must also complete OP 160 and OP198.
All eligible titles Claim for Loss or Damage to Personal Property (OP504)  

This form is used to claim for loss or damage to personal property. Students and non-DOE employees are not eligible for reimbursement by the Medical Administration Claims Unit.

UFT and CSA pedagogical titles only Claim for Reimbursement of Medical Expenses (OP505) This form is used to claim for medical expenses from an approved line of duty injury.
All titles OP 200 Assignment Form This form is used when claiming absences as a result of a line of duty accident or incident. Must be signed and notarized.
Eligible UFT titles as specified in the UFT contract Hardship Transfer Application This form is used to apply for hardship transfer.
All titles

Accommodation Request Form: Personnel Memorandum #4, 2009-10

This form is used to request accommodation for all qualified individuals with disabilities. Supporting medical documentation and description of job duties must accompany this form.
All titles Conditional Offer of Employment Medical Form Some applicants are required to provide medical documentation to determine fitness prior to employment with DOE. Applicants are notified at the time of the employment offer if this form is necessary.

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Certification and Credentialing

Employee Population  Forms                                  Notes
Prospective Teachers (seeking certification) DOE Road to Certification Workshop Application This workshop will provide information on becoming a New York State certified teacher. Please see application for workshop dates. Visit the Teach NYC Web site  for more information. 
NYSED "Professional" Certificate Holders 175 Professional Development Tracking Form This form is used  by NYSED "Professional" certificate holders to submit their completed professional development hours to the Office of Certification and Licensing.

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Excessing, Transfers, and Job Changes

Employee Population  Forms                    Notes 
Pedagogical personnel Application for Reduction of Probationary Service Pedagogical personnel can apply for a reduction of the standard probationary period based on previous teaching services provided in the state of New York.
Pedagogical personnel Application for Layoff Seniority Credit for Paraprofessional Service Pedagogical personnel with a regular license appointment can claim prior paraprofessional service for layoff seniority credit. 
Teachers Teaching Service Verification Form (Rule 3) Eligible teachers serving in an out-of-license or out-of-level assignment can apply for Rule 3 excessing seniority credit.
School-based staff in UFT-covered titles except for paraprofessionals Veterans’ Seniority Credit Verification Request Form School-based staff in UFT-covered titles, except for paraprofessionals, can claim their previous military service for excessing/layoff seniority credit.
UFT-Educational paraprofessionals Veterans’ Seniority Credit Verification Request Form for educational paraprofessionals UFT-Educational paraprofessionals can claim their previous military service for excessing/layoff seniority credit. 

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Professional Development

Employee Population   Forms                             Notes
Paraprofessionals Summer Stipend Application Paraprofessionals attending and completing six (6) credits/semester hours of study during the summer semester may be eligible to receive a summer stipend.

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Recommencement of Service

 Employee Population Forms    Notes
Non-supervisory pedagogical personnel Application for Withdrawal from Resignation/  Retirement Non-supervisory pedagogical personnel are required to complete and submit the form in order to return to service following their retirement/resignation.

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