Forms

Your personnel office can provide paper copies of many of these forms.

Please note:

• Some forms can't be filled out on your computer. You'll need to print them and fill them out by hand.
• Forms that can be filled out on your computer generally can't be saved. You'll fill them out on your computer and print them each time you use them.
• You can't submit these forms online or by email.

You can also get standard forms from the DGS Office of State Printing website.

To find publications, please visit our Publications page.

Annual Leave

• Annual Leave - Sick Leave/Vacation - Election Form (PDF)

 

Cash Options

Consolidated Benefits (CoBen)

For excluded employees and eligible represented employees in bargaining units 2, 7, 8, 16, 17, 18, and 19.

• Consolidated Benefits Cash Enrollment Election Form - STD 702 - PDF

Cash Options

For all other employees.

• Cash Option Enrollment Authorization - STD 701C - PDF
• CalPERS Health Benefits Enrollment Form - HBD-12 - PDF | Instructions
• Dental Enrollment Form - STD 692 - PDF

 

CEA and Exempt Appointees - forms for Personnel Offices

• CEA Return Rights Worksheet
• Exempt Return Rights Worksheet

Dental

All forms are PDFs unless otherwise noted.

• Dental Plan Enrollment Authorization - STD 692
• Dental Plan Direct Payment Authorization - STD 696
• Affidavit for Economic Dependent Children - DPA 025 - Word Document
• Affidavit for Domestic Partners or Same-Sex Spouses Being Claimed as Economic Dependents - DPA 680

Dental COBRA Forms

• COBRA Initial General Notice (Word Document)
• COBRA Initial General Notice Log (Word Document)
• COBRA Election Notice (Word Document)
• COBRA Election Notice Log (Word Document)
• COBRA Election Form (PDF)
• COBRA Notice of Unavailability of Continuation Coverage (Word Document)
• COBRA Monthly Status Report (Word Document)
• COBRA Calendar (PDF)
• COBRA Premium Assistance and Election Notice - American Reinvestment and Recovery Act of 2009 (PDF)

 

Employee Suggestion Program

For Employees/Suggesters

• Employee Suggestion Form - STD 645 (PDF)

For Evaluators

• Employee Suggestion Evaluation Report - STD 645A (PDF)

 

Family and Medical Leave Act (FMLA)

• "Notice of Eligibility and Rights and Responsibilities" (DPA 752) - PDF | Word Document fill-and-print
• "Designation Notice" (DPA 753) - PDF | Word Document fill-and-print
• "Certification of Health Care Provider for Employee's Serious Health Condition" (DPA 754) - PDF | Word Document fill-and-print This new and improved form adds a section for essential functions of the job and adds a section for the health provider to put the actual time an employee may need intermittent leave.
• "Certification of Health Care Provider for Family Member's Serious Health Condition" (DPA 755) - PDF | Word Document fill-and-print
• "Certification of Qualifying Exigency for Military Family Leave" (Family and Medical Leave Act) (DPA 756) - PDF | Word Document fill-and-print
• "Certification for Serious Injury or Illness of Covered Servicemember for Military Caregiver Leave" (DPA 757) - PDF | Word Document fill-and-print

 

FlexElect Reimbursement Accounts

• Reimbursement Account Enrollment Authorization - STD 701R - PDF
• FlexElect Reimbursement Claim Form - DPA 351 - PDF
• Premium Only Plan Request for Disenrollment - DPA 006 - PDF
• Letter of Medical Need - ASI - PDF
• Qualified Reservist Distribution (QRD) Request Form - DPA 902 - PDF

Reimbursement Accounts COBRA Forms

• COBRA Election Form - DPA 689 (PDF)
• COBRA Initial Notice (Word Document)

 

Grievances

• Employee Contract Grievance - STD 630 -Word Document
• Excluded Employee Grievance - STD 631 - Word Document

 

Layoff

Forms from Section 400 of the Layoff Manual

• Prior Exempt Service Questionnaire - DPA 004 (PDF) | Word Document
• Verification of State Service (Outside the Executive Branch) - DPA 039 (PDF)
• Military Service Information - DPA 190 (PDF) | Word Document
• Verification of Total State Service - DPA 690 (PDF)
• Military Service Qualification Worksheet (PDF)

Forms from Section 700 of the Layoff Manual

• Layoff Plan and Request for Preliminary Seniority Scores - DPA 009 (Word Document) | Instructions (PDF)
• Notice of Involuntary Transfer, Demotion, or Termination - DPA 015 (PDF)
• Report of Current Performance - DPA 040 (PDF)

Forms from Section 900 of the Layoff Manual

• Establishing Reemployment Lists - DPA 016 (PDF) | Instructions (PDF)

 

Medal of Valor

• Governor's State Employee Medal of Valor Special Act / Special Service Award Nomination - DPA 012 (PDF)

 

Merit Award

• Superior Accomplishment Gift or Cash Award Recommendation - STD 278 (PDF)
• Governor's State Employee Medal of Valor Special Act / Special Service Award Nomination - DPA 012 (PDF)

 

Military Leave

• Military Leave Worksheet (PDF)
• "Certification of Qualifying Exigency for Military Family Leave" (Family and Medical Leave Act) (DPA 756) - PDF | Word Document fill-and-print
• "Certification for Serious Injury or Illness of Covered Servicemember for Military Caregiver Leave" (DPA 757) - PDF | Word Document fill-and-print

 

Negri Award

• Nomination form (PDF)

 

Partial Service Retirement

• Partial Service Retirement Application - DPA 062 (PDF)

Pre-tax Parking

• Account Enrollment Form - DPA 682 (PDF)
• Account Claim Form - DPA 681 (PDF)

 

Retired Annuitant Certification

• Retired Annuitant Self-Certification - DPA 715 (PDF)

 

Seniority

• Final Seniority Score Package - DPA 700 - Word document

State Restriction of Appointments

• SROA Scantron Form (PDF)
• SROA/ISWAP Worksheet (PDF)

 

Travel, Relocation, Reimbursement

• Travel Expense Claim - STD 262 (PDF)
• Hotel/Motel Transient Occupancy Tax Waiver - STD 236 (PDF)
• Excess Lodging Rate Approval (with Attachment ) - STD 255C (PDF)
• Out-of-State Travel Approval Request - STD 257 (PDF)
• Out-of-State Travel Approval Request (Trip Description) - STD 257C (PDF)
• Blanket Approval for Out-of-State Travel - STD 260 (PDF)
• Authorization to Use Private Owned Vehicle on State Business - STD 261 (PDF)
• Insurance Verification & Authorization to Operate Privately Owned/Rented/Leased Aircraft on State Business - STD 265 (PDF)

 

Vision Benefits

• Vision Plan Enrollment Authorization - STD 700 (PDF)
• Vision Plan Direct Payment Authorization - STD 703 (PDF)
• Retiree Vision Plan Deduction and Enrollment Authorization - DPA 695 (PDF)
• Vision Services Plan Brochure/Enrollment Form (PDF)

Vision COBRA Forms

• COBRA Initial General Notice (Word Document)
• COBRA Initial General Notice Log (Word Document)
• COBRA Election Notice (Word Document)
• COBRA Election Notice Log (Word Document)
• COBRA Election Form (PDF)
• COBRA Notice of Unavailability of Continuation Coverage (Word Document)
• COBRA Monthly Status Report (Word Document)
• COBRA Calendar (PDF)
• COBRA Premium Assistance and Election Notice - American Reinvestment and Recovery Act of 2009 (PDF)

 

Workers' Compensation

Please visit our Publications page to get the Workers' Compensation Claim Kit.

Updated April 14, 2011 at 11:41 AM.