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Forms

Form types:

PDF printable (This form type must be printed to be filled by pen and submitted in person)
web fillable (This form type can be accessed thru web browser and submitted online, for on-campus use only)

General Forms
Benefits
Overtime, Time & Leave
Training & Development

General Forms
	CUNY Employment Application (for New or Re-Hire) College Assistant Work Schedule Confirmation Inter-College Transfer Application (Competitive Titles) Inter-College Transfer Application (Labor or Non-Competitive Titles ) Multiple Positions Form Reasonable Accommodation Request Form Health Care Provider Assessment Form
Benefits
	New Hire Benefits Forms
	*Open Enrollment Forms* Health Benefits Application PSC-CUNY WF Change in Status Form Flexible Spending (FSA) Form Buy Out Waiver Form Password Protection Instructions Catastrophic Forms City Health Benefits View Basic Health Plan and Optional Rider Rate Chart for Employees View Basic Health Plan and Optional Rider Rate Chart for Retirees Health Benefits Application Dependent Eligibility Required Documentation COBRA Form, Notice of Rights and COBRA Rates Young Adult Option Through Age 29 (NYS Law Chapter 240) New York State Marriage Equality Act Health Benefits Summary Plan Description (SPD)
	CUNY Adjunct Health Insurance Adjunct Health Insurance Enrollment Packet Adjunct Healthcare Information and Procedures CUNY Adjunct Health Insurance Enrollment Packet Adjunct PSC/CUNY Family Enrollment Form Adjunct FAQs Additional Forms PSC/CUNY Welfare Fund Information, Forms, and Procedures Information on NYC Health Benefits Program Health Plans Adjunct Retirement Benefits, Voluntary Benefits and Tax-Deferred Annuity (TDA) Plans, and 457(b) Plan
	Ending Employment Forms COBRA Notice of Rights and Health Benefit Rates DC 37 (link to another site) PSC CUNY (link to another site) PSC CUNY COBRA Application Exit Clearance Sign-off
	Flexible Spending Account Forms Plan Year 2023 Flexible Spending Accounts Program Plan Year 2023 FSA Enrollment/Change Form Plan Year 2023 MSC Health Benefits Buy-Out Waiver Enrollment/Change Plan Year 2023 MSC Premium Conversion Enrollment/Change Form Plan Year 2023 HCFSA/DeCAP SPD Plan Year 2023 MSC SPD 2023 DeCAP Claims Form 2023 HCFSA Claims Form
	FMLA Forms FMLA Policy FMLA Form #1 - Request for FMLA FMLA Form #3A - Certification from Physician FMLA Form #6 - Fitness For Duty Certification Family FMLA Forms FMLA Policy Steps to Follow for Family FMLA FMLA Form #1 - Request for FMLA FMLA Form #3B - FMLA Certification of Physician FMLA Form #5 - Certification of Family Relationship Non-FMLA Forms Application for Non-FMLA Medical Leave Non-FMLA Fitness for Duty Certification
	Other Benefits Forms Domestic Partnership Packet GHI Health & Wellness GHI Discount Programs Long-Term Disability Benefits Claim Packet (PSC CUNY) Park-N-Ride Plan Enrollment Form PSC-CUNY Member Update Retiree Change of Address Form Short-term Disability Benefit Claim Form (DC 37) TransitBenefit Enrollment Form Weight Watchers Reimbursement Form 511 Rideshare (link to another site)
	Pre-Retirement Planning PSC Retirement Information CUNY EAP CCA Link

	Phased Retirement Phased Retirement Summary Phased Retirement Application- Professional Staff Phased Retirement - Faculty Phased-Retirement Signed Agreement

	Pre-Tax Savings Plans New York 529 College Savings Enrollment Application TIAA Salary Reduction form New York State Deferred Compensation 457 Plan New York City Deferred Compensation 401(K) Retirement Plan - Community Colleges Only
	Retirement Forms Application for Retirement (Classified Staff) Application for Retirement (PSC Staff) Phased Retirement Faculty Application-Standard-9-18-15 PSC-CUNY: Retiree Enrollment Form TIAA-CREF Medicare-Eligible Retirees Application for Medicare (Part B) Reimbursement
	Worker’s Compensation Forms Employees should be filled out with a dark pen and legible (please print). Worker’s Compensation Election of Options (DP-2002) Worker’s Compensation Claim Form C-3 Worker’s Compensation Employee's Statement of Injury Supervisors must fill out and forward to HR the following forms within 48 hours of the injury/illness: Worker’s Compensation Accident Description Codes Worker’s Compensation Supervisor's Report of Injury Worker’s Compensation Witness Statement

Time & Leave
	Dedicated Sick Leave - Application to Donate Dedicated Sick Leave - Application to Receive Application for Leave for Special Purposes: Instructional Staff (Teaching and Non-Teaching) Only Child Care Leave of Absence Application (Unpaid) - Classified Staff Only Child Care Leave of Absence Application (Unpaid) - Instructional Staff Only Paid Parental Leave Compensatory Time Authorization Form - Classified Staff Fellowship Leave Application Application for Scholar Incentive Award Library Reassignment Form Partial Leave of Absence With Partial Pay Special Leave of Absence Without Pay 35-Hours Employees Summer Hours Program Options 40-Hours Employees Summer Hours Program Options
Training & Development
	Citywide Training Center Application (NYC Department of Citywide Administrative Services) PDLM E-Application Program/Course Application (OHRM Professional Development & Learning Management Office) Tuition Fee Waiver

	Additional Benefits Forms

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