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    FormsNotes
All titlesOSPRA 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 titlesOSPRA 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 FormThe NYC Department of Education no longer accepts paper Fingerprint Referral form. This form is completed electronically via an online application system.
All titlesEmployment Eligibility Verification (I-9) formThe NYC Department of Education no longer accepts paper I-9 form. This form is completed electronically via an online application system.
All titlesBackground Questionnaire FormThe NYC Department of Education no longer accepts paper Background Questionnaire form. This form is completed electronically via an online application system.
All titlesConditional 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 PopulationFormsNotes

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 titlesApplication Form for NYC DOE Photo ID CardThis 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 FormsNotes
All titlesPersonal 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 PopulationFormsNotes
All titlesDirect Deposit FormThis form is used to sign up for direct deposit of your paycheck.

All titles
W-2 Duplicate Request and Information Correction FormThis form is used by any employee that needs to request a replacement W-2 for the last three years.
 All titlesStop Payment FormThis 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 FormThis form is used by payroll secretaries and timekeepers to stop a paycheck payment for T-Bank employees.
 All titlesTransitBenefit PlansThis document contains information about WageWorks.
All titlesAccess-A-RideThis form is used to enroll, update, or cancel Access-A-Ride Benefits.
All titlesPark-And-RideThis form is used to enroll, update, or cancel Park-And-Ride Benefits.

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Loan Forgiveness

Employee PopulationFormsNotes
 All titlesThird-party formsPlease 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 

Please note that HR Connect will not fill out  third party forms.

Employee PopulationFormsNotes
 All titlesEmployment Verification FormThis form is used to request employment information for a DOE employee, such as salary and start date.
 RetireesEmployment Verification For for Pension PurposesThis 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 titlesUse Employee Self-Service: nyc.gov/ESSEmployee 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 ApplicationThe 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 CoversheetThe 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.   
Payroll SecretaryHealth 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 2016)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.

RetireesERB Health Benefits ApplicationRetirees 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 PopulationForms Notes 
Administrative Staff and Supervisory Staff (including Principals, Assistant Principals and Education Analysts)Request for Leave under the Family and Medical Leave Act (FMLA) formThis form is used to apply leave of absence for personal illness, maternity child care, maternity disability, care of sick child/family member. Non-Supervisory Pedagogical, UFT Education Paraprofessionals, Family Paraprofessionals, School Aid titles, and Health Aid titles must now use SOLAS to apply for their Leaves.

Leaves Without Pay

Employee Population FormsNotes
Non-Supervisory Pedagogical Employees onlySubmit forms online via Self-Service Online Leave Application System (SOLAS)Non-Supervisory Pedagogical employees must use SOLAS to apply for all leave types.
Supervisory Staff (including Principals, Assistant Principals and Education Analysts) 

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, and non-medical leaves. To apply for a restoration of health leave, you must complete OP407, OP160 and OP198. To apply for a military leave, you must complete OP160-1
Administrative Staff only 

PD 6: Leave of Absence for Health Reasons

 

Application for Non-Medical Leave of Absence

The PD 6 form is used to apply for leave of absence for health reasons. There is no minimum service requirement for permanent employees, however, provisional employees must have worked a minimum of 1250 hours in order to qualify for this leave.


The Application for Non-Medical Leave of Absence form is used to apply for Adjustment of Personal Affairs; Care of a Sick Family Member; Childcare; Military; and Study Sabbatical Leaves.
Family Paraprofessionals & Hourly Non-Competitive Employees only 

Family Paraprofessional & Hourly Non-Competitive Employee Leave Application

 

All Leave types are available in SOLAS for quicker processing.

This form is used to apply for a Leave of Absence without pay for Family Paraprofessionals and hourly Non-Competitive employees.

Paper applications will be accepted until further notice.

UFT Educational Paraprofessionals onlyEducational Paraprofessionals -- Leave ApplicationUFT Educational Paraprofessionals must use SOLAS to apply for all Leave types.
Supervisory Staff & Administrative Staffs onlyOP 160-1: Application for Military Leave of Absence Non-supervisory Pedagogical, UFT Education Paraprofessionals, Family Paraprofessionals, School Aid Titles, and Health Aid Titles must use SOLAS to apply for Military Leaves of Absence.

This form is used to apply for military leave of absence without pay.

Leaves With Pay

Employee  Population  Forms Notes 
Administrative Staff onlyLeave of Absence with Pay Recommendation FormThis form is used to apply for medical leave without pay or with pay.  PD 6: Leave of Absence for Health Reasons must be attached.
Non-Supervisory Pedagogical Employees onlySubmit forms online via Self-Service Online Leave Application System (SOLAS)Non-supervisory pedagogical employees must use SOLAS to apply for all leave types.
Supervisory Staff (including Principals, and Assistant Principals)OP 8: Application for CSA Sabbatical Leave of Absence

Addendum to Study Sabbatical application for changes in coursework



Waiver to work while on Study Sabbatical Application



These forms are used to apply for sabbatical leave of absence.






This form can be used by Pedagogical and Supervisory Staff to apply for a Waiver to work while on a Study Sabbatical.
Supervisory Staff & Administrative Staffs only OP 160-1: Application for Military Leave of Absence 

Extended Military Benefits Program Enrollment For (DP-2520)


Non-supervisory pedagogical, UFT Education Paraprofessionals, Family Paraprofessionals, School Aid Titles, and Health Aid Titles must use SOLAS to apply.

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 onlyPD 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.
Family Paraprofessional & Hourly Non-Competitive EmployeesPD 19H (Family Paraprofessional & Hourly Non-Competitive Employee Application for Excused Absence with Pay)This form is used to apply for leave of absence with pay for Family Paraprofessional & Hourly Non-Competitive 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. Interested employees must be eligible for retirement and have enough CAR time available. This leave must be applied for no later than 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 PayThis form is used to apply for Terminal Leave of Absence with pay. Interested employees must be eligible for retirement. Application must be submitted no later than 30 days prior to the start date of retirement.
Non-Supervisory Pedagogical Employees onlyRetirement 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 onlyUFT Educational Paraprofessionals - Borrowing Sick Days ApplicationThis form is used to borrow sick days for personal illness. The application must be accompanied by a signed/stamped diagnostic physician’s note that states the nature of the illness.
Administrative Employees, Hourly Support Staff onlyDonation of Leave for Illness Form: E745, Q744, H740This 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 onlyCAR Transfer Form - For PedagoguesThis 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    FormsNotes 
Instructional Staff onlyOP 407 (Confidential Medical Report and Medical Evaluation Form)This form is used to document medical report and evaluation for Medical Leave of Absence. Important: Supervisory staff must complete OP 160 in addition to the OP407.
Non-supervisory pedagogues must apply in SOLAS.
All eligible titlesClaim for Loss or Damage to Personal Property (OP504) 

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

UFT and CSA pedagogical titles onlyClaim for Reimbursement of Medical Expenses (OP505)This form is used to claim for medical expenses incurred from an approved Line of Duty Injury (LODI).
Non-Pedagogical Employees onlyEmployee Instructions for Workers' CompensationUFT Education Paraprofessionals, Family Paraprofessionals, School Aid Titles, and Health Aid Titles must useSOLAS to apply for Workers' Compensation Leaves of Absence.

All other titles must continue to use the paper application form.
All titlesOP 200 Assignment FormThis form is used when claiming absences as a result of a Line of Duty accident or incident. The completed form must be signed and notarized.
Eligible UFT titles as specified in the UFT contractHardship 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 an accommodation for all qualified individuals with disabilities. The submitted form must also include supporting medical documentation and description of job duties.
All titlesConditional Offer of Employment Medical Form This form is to be used by those applicants who are required to provide medical documentation in order to determine fitness prior to employment with the DOE. Applicants will be notified at the time of the employment offer if this form will be required.

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Certification and Credentialing

Employee Population Forms                                  Notes
Prospective Teachers (seeking certification)DOE Road to Certification Workshop ApplicationThis 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 Holders175 Professional Development Tracking FormThis 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 personnelApplication for Reduction of Probationary ServicePedagogical personnel can apply for a reduction of the standard probationary period based on previous teaching services provided in the state of New York.
Pedagogical personnelApplication for Layoff Seniority Credit for Paraprofessional ServicePedagogical personnel with a regular license appointment can claim prior paraprofessional service for layoff seniority credit. 
TeachersTeaching 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 paraprofessionalsVeterans’ 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 paraprofessionalsVeterans’ Seniority Credit Verification Request Form for educational paraprofessionalsUFT-Educational paraprofessionals can claim their previous military service for excessing/layoff seniority credit. 

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Professional Development

Employee Population  Forms                             Notes
ParaprofessionalsSummer 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 PopulationForms   Notes
Non-supervisory pedagogical personnelApplication 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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