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	This form is used to release fingerprint results from NY State Education Department to NYC Department of Education. Important: Applicants must submit an OSPRA 103 Form, nomination/referral letter or email, and Fingerprint Referral Form (Moral Questionnaire) by coming to the HR Connect Walk-in Center (65 Court Street) in person with 2 original forms of personal identification that show eligibility to work in the U.S.
All titles	OSPRA 104	This form is used to release fingerprint results from NYC Department of Education to NY State Education Department. Important: Applicants must bring completed OSPRA 104 Form, I-9 Form, and 2 original forms of personal identification listed on page 9 of the I-9 Form to the HR Connect Walk-in Center (65 Court Street). Teachers, substitute teachers, teaching fellows, and substitute paraprofessionals do not need to submit the OSPRA 104 because their fingerprint results are automatically sent to NYSED.
All titles	Fingerprint Referral Form	This form is required for fingerprint processing is and usually completed electronically.
All titles	Employment Eligibility Verification (I-9) form	This form is used to verify an individual’s eligibility to work in the United States. Titles that are not payrolled by DOE are not required to meet I-9 requirements.
Per diem or per session employees (except for substitute paraprofessionals)	Moral Questionnaire Form	This form is a part of the pre-employment background check process.
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.

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.

Personal and Tax Data Changes

Employee Population	Forms	Notes
All titles	Personal and Tax 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.

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	WageWorks Form	This form is used to update, enroll, or cancel TransitBenefit enrollment. For more information, click Expanded TransitBenefit Program with WageWorks.

Loan Forgivness

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.

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.

Health Benefits

Employee Population	Forms	Notes
All eligible titles	ERB Health Benefits Application	The ERB form is used to process changes to benefits elections during the annual transfer period or as a result of a qualifying event (e.g. changing dependent coverage as a result of marriage, domestic partnership, birth of a child, adoption, or divorce).
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.
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 Coversion Form (Plan Year 2013)	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.

Leaves

FMLA (Family and Medical Leave Act)

Employee Population	Forms	Notes
Administrative Staff andPedagogical 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)	Only non-supervisory pedagogical employees are eligible to apply for a non-medical leave of absence via SOLAS.
Instructional Staff (including CSA and UFT Staff)	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 Page 1 (Confidential Medical Report and Medical Evaluation Form) and OP 407 Page 2 and OP 407 Instructions	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.
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	Educational Paraprofessionals – Leave Application	This form is used to apply for leave of absence without pay for UFT Educational Paraprofessionals

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.

Instructional Staff (including CSA Staff)

OP 8: Application for Sabbatical and Statement by Applicant

Addendum to Study Sabbatical application for changes in coursework

Waiver to work while on Study Sabbatical Application

This form is used by instructional staff to apply for sabbatical leave of absence.

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.

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.

Medical

Employee Population	Forms	Notes
Instructional Staff only	OP 407 Page 1 (Confidential Medical Report and Medical Evaluation Form) and OP 407 Page 2 and OP 407 Instructions	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.

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.

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.

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.

Recommencement of Service

Employee Population	Forms	Notes
Non-supervisory pedagogical personnel	Application for Withdrawal from Resignation/ Retirement AND Authorization for Release of Information	Non-supervisory pedagogical personnel are required to complete and submit both of these forms in order to return to service following their retirement/resignation.