FREQUENTLY USED FORMS

EB 1054 HEALTH BENEFITS TRANSMITTAL (used to notify health insurance carrier
of SLOAC, FMLA, termination, reinstatement, change of title or address or
specific problems that require an explanation.

ERB 97 HEALTH BENEFITS APPLICATION (used for application for health
insurance benefits for new employees, reinstatement, retirement, change
optional benefits, change of spouse, domestic partner, dependent children.
This requires documentation such as verified copies of marriage or domestic
partner certificate, birth certificate.

FINAL ENTITLEMENT FORM - This must be submitted for every employee who is
removed from payroll: i.e., resignation, leave of absence without pay,
retirement.)

FMLA FAMILY MEDICAL LEAVE ACT - You must have been on payroll for 12 months
(full time) before eligible to receive up to 12 weeks leave of absence.

OP 40 APPLICATION FOR RETIREMENT LEAVE OF ABSENCE (Terminal Leave)
Pedagogues are eligible to apply for this. The form must be filed 30 days
in advance of the leave and can only cover one term. The ratio is one-half
of sick leave balance.

OP 44 APPLICATION FOR TERMINATION PAY (used for the employee to receive
termination pay on the basis of one-half of the unused sick leave accumulated
in the CAR. Maximum days allowed in CAR is 200 days for appointees and 120 days for regular substitutes.
Get an OP 44 Form

OP 85 PERSONNEL CHANGE FORM (for changes in name, address, tax status)

OP 160 APPLICATION FOR LEAVE OF ABSENCE WITHOUT PAY

OP 198 APPLICATION FOR EXCUSE OF ABSENCE FOR PERSONAL ILLNESS AND MEDICAL CERTIFICATION..

OP 198AR APPLICATION FOR BORROWED SICK LEAVE DAYS

OP 201 APPLICATION FOR EXCUSE OF ABSENCE WITHOUT PAY AND/OR NON-ATTENDANCE

OP 221 APPLICATION TO ATTEND SCHOOL MEETING OR CONVENTION OUTSIDE NEW YORK CITY

OP 255 - RESUMPTION OF SERVICE Form - used when an employee is returning from a
leave of absence without pay

OP 407 CONFIDENTIAL MEDICAL REPORT AND MEDICAL EVALUATION - Used for excuse
of absence for more than 20 days, excuse of absence for alleged line of duty accident,
sabbatical leave for restoration of health, leave of absence without pay for
restoration of health. See instructions on this form for other forms required in
conjunction with the above.

APPLICATION FOR SALARY DIFFERENTIAL - (for additional education credits)
Individuals who submit an application for a differential may file within a
six month period* from the date of appointment or placement on payroll as a
regular substitute or completion of coursework in order to receive
retroactive payment from date of eligibility. Late filing results in loss of
money because the effective date will be the first day of the month following receipt
of the application. (See Personnel Memo No. 14, 1999-2000). It is strongly
recommended that this form be delivered in person and that you get a receipt.
Keep copies of everything for your own records.

APPLICATION FOR SALARY STEP PLACEMENT- This form must be filed by the
pedagogue who is newly appointed, whether claiming prior experience or not.
It also may be filed by substitute personnel who want to receive salary
credit for allowable prior outside experience related to the license. In
order to receive credit retroactive to the date of appointment or placement
on payroll as a regular substitute you may file within a six month period
*after the qualifying event in order to receive retroactive payment.
Late filing results in loss of money because the effective date will be the
first day of the month following receipt of the application.
(See Personnel Memo No. 14, 1999-2000). It is strongly recommended that
this form be delivered in person and that you get a receipt. Keep copies of
everything for your own records.

* Effective 9/1/99

UFT Welfare Fund forms: Contact UFT Welfare Fund at 212-539-0590 or check
the web site at www.uft.org/welfare

***

If you need a small supply of some of these forms send your request to
UFTSecy@aol.com. Make sure to include your name and school address.




Print Forms