Human Resources - Forms

Links to some of the most frequently requested forms are listed below. If you do not see the form you need, please contact the Office of Human Resources. Additional forms are always available and can be requested by phone at 315-792-7191 or e-mail at

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Form Fill-in
PDF/Link Fill-in
Benefits (Health Insurance, Retirement, Flex Spending, Tuition Waiver)
Dental Claim Form (CSEA)   (.pdf)  
Dental Claim Form (MC)   (.pdf)  
Dental Claim Form (UUP)   (.pdf)  
Dependent Care Reimbursement   Form | Instructions  
Domestic Partner Instructions/Enrollment   (.pdf)  
Empire Plan Out of Network Claim   (.pdf)  
Health Care Spending Account Reimbursement Request   Form  
Tuition and Fee Assistance (B-140W) (.doc) (.pdf) (.pdf)
UUP Tuition Waiver     (.pdf)
Vision Care Reimbursement (CSEA)   (.pdf)  
Vision Care Reimbursement (UUP)   (.pdf)  
Vision Claim Form (MC)   (.pdf)  
Extra Service

Dual Employment/Extra Service Approval
(To serve with another state agency)

Request for Approval of Extra Service for UUP Employees (UP-8)   (.pdf)  
Request for Approval of Extra Service for M/C Employees (UP-6)   (.pdf)  
Leaves & Resignations
Request for Sabbatical Leave of Absence - Faculty (.doc)    
Check-Out Form   (.pdf)  
Title F Leave (.doc)    
Miscellaneous Forms
Review of Personnel File Request (.doc)    
Voluntary Self-Identification of Disability      
SUNY Poly Bias Report form      
Acknowledgement of Compliance with SUNY Board of Trustee’s and SUNY Polytechnic Institute campus policies and procedures (.doc)    
Hiring Pause Protocols   (.pdf)  
Requesting a Hire / Search / Changing Employment Status of a SUNY Poly Employee   (.pdf)  
Application to Request Reasonable Accommodation of Disability   (.pdf)  
Part A - Request Reasonable Accommodation   (.pdf)  
Payroll Forms
Change of Address/Name   (.pdf)  
Direct Deposit     (.pdf)
Direct Deposit Reactivation     (.pdf)
IT-2104 (NYS) Employee's Withholding Allowance Certificate     (.pdf)
Salary Reduction Agreement   (.pdf)  
W4 (Federal) Employee's Withholding Allowance Certificate     (.pdf)
Time and Attendance
UUP Non-Exempt Timesheet   (pdf)  
Classified Staff Timesheet   (pdf)  
Daily Time Record   (pdf)  
Time and Attendance for Students
Graduate Assistant Timesheet   (pdf)  
Performance Program & Evaluation
Performance Evaluation Program and Appraisal for Classified Staff (CSEA)
2016 sample (pdf)
(.doc) (.pdf) (.pdf)
Management Confidential (Supervisor) Program (.doc) (.pdf)  
Management Confidential (Supervisor) Evaluation (.doc) (.pdf)  
Management Confidential (Non-Supervisor) Program (.doc) (.pdf)  
Management Confidential (Non-Supervisor) Evaluation (.doc) (.pdf)  
Professional Performance Evaluation (UUP) (.doc) (.pdf)  
Professional Performance Program (UUP) (.doc) (.pdf)  
Professional, Scientific & Technical Services Unit Evaluation Form (PEF) (.doc) (.pdf) (.pdf)
Performance Management Outline (.xlsx)    
Employment Application   (.pdf)  
Job Description Template (.doc)    
Recruitment Guidelines   (.pdf)   
Appointment Request Checklist   (.pdf)   
I-9     (.pdf)
UUP Professional Request for Promotion or Salary Increase      
Guidelines, Instructions and Procedure   (.pdf)  
Application for Promotion or Salary Increase (.doc)    
Promotion or Salary Increase Appeal (.doc)    


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