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Tools and Forms

All forms are viewable using Adobe Acrobat (.pdf), unless otherwise noted.

Use the search box below to look for the form you need or use the column headers to sort the forms alphabetically or by form type.

Form Name Form Type
415(g) Aggregation Form Benefits
Accrual Bank Adjustment - used to make increases/decreases to an individual's time off accruals. Payroll
Adoption Reimbursement Request Form Benefits
Aetna HealthFund Health Option Benefits
Aetna Plus Health Option (formerly Aetna Standard)
 Benefits
Aetna Claim Form (for domestic and international claims) Benefits
Beneficiary Change (Life and AD&D Insurance) Benefits
Benefits Overview 2013 for Faculty and Staff (requires VUnetID)
Benefits Overview 2013 for Faculty and Staff Candidates (no VUnetID required)		 Benefits
BlueCross BlueShield DentalBlue PPO - Claim Form Benefits
BlueCross BlueShield DentalBlue PPO - Evidence of Coverage Booklet (2012) Benefits
BlueCross BlueShield DentalBlue PPO - Summary of Benefits Benefits
BlueCross BlueShield of Tennessee Select Health Option Benefits
BlueCross Claim Form (CMS-1500)

BCBST Claims Service Center
1 Cameron Hill Circle, Suite 0002
Chattanooga, TN 37402-0002

 Benefits
Cigna Dental Care (DHMO) Summary Plan Description Benefits
CIGNA Dental Care (DHMO) Summary Sheet for 2012 (Patient Charge Schedule) Benefits

CIGNA Dental Care (DHMO) Summary Sheet for 2013 (Patient Charge Schedule)

 Benefits
Continuation of Benefits Application Form - COBRA (2012) Benefits
Continuation of Benefits Application Form - COBRA (2013) Benefits
Continuation of Benefits Form While on Unpaid Leave Benefits
Criminal Background Disclosure Process Employment

Dependent Information Change Form

  • Use this form to change/correct information that HR has in your employee record for your dependent children, spouse or domestic partner.
 Benefits

Direct Deposit Enrollment

Payroll
Employment Law Posters Employment
Exit Interview Questionnaire Employment
Family and Medical Leave Act (FMLA) FMLA
Family Status Change Request Benefits
Flexible Reimbursement Account (FRA), see "Health Reimbursement Account" Benefits
Flexible Spending Account (FSA). Enroll with the Benefits Enrollment link on the C2HR website.
  1. Claim Form
  2. Eligible Expense List
  3. Flexible Spending Account (FSA) Summary Plan Description
Benefits
Health Care Plan  Summary Plan Description Benefits
Health Care Plan Waiver Form Benefits
Health Reimbursement Account (HRA)
[formerly Flexible Reimbursement Account (FRA)]
NOTE: To be eligible for the HRA, your five-year waiting period must have started before December 31, 2004. If you started working at Vanderbilt on or after January 1, 2005, you are not eligible.
  1. Claim Form
  2. Health Reimbursement Account (HRA) Summary Plan Description
Benefits
HealthFund Health Option — Evidence of Coverage Booklet Benefits
Life and Accidental Death & Dismemberment Summary Plan Description Benefits
Life Insurance Drop Form (Supplemental Life) Benefits
Long-Term Disability Certification of Prior Coverage Form Benefits
Long-Term Disability Summary Plan Description Benefits
Full Long-term Disability Plan Waiver Benefits
Medicare Part D Notice of Credible Coverage Benefits
MetLife Statement of Health Form Benefits
Navitus Drug Claim Form Benefits
Navitus Foreign Drug Claim Form
(Use this form for prescriptions that were purchased outside of the United States) 		Benefits
Navitus Pharmacy Booklet (2013)  
Notice of Privacy Practices Benefits
Notification of Family Status Change Benefits
Payroll Correction Request - used for any event that includes the word prior (prior overtime, prior hours worked, prior increase to salary, etc.) Payroll
Personal Spending Account, see"Flexible Spending Account" Benefits

Progressive Discipline

 
Retirement Plan Forms:
  1. Retirement Plan Election Form (Salary Reduction Agreement) . This form is used to begin or change your contributions to the Vanderbilt Retirement Plan. You may make changes to your contributions using this form once a calendar quarter. This form must be submitted with a retirement company form, if you are opening a new account with that company.
  2. Fidelity Application. Use this form to open an account with Fidelity. This should be submitted with the Vanderbilt Retirement Plan Contribution and Allocation Form (see #1 above)
  3. TIAA-CREF RA/GSRA Application. Use this form to open an account with TIAA-CREF. This should be submitted with the Vanderbilt Retirement Plan Contribution and Allocation Form (see #1 above)
  4. VALIC Application. Use this form to open an account with VALIC. This should be submitted with the Vanderbilt Retirement Plan Contribution and Allocation Form (see #1 above)
  5. Vanguard Application. Use this form to open an account with Vanguard. This should be submitted with the Vanderbilt Retirement Plan Contribution and Allocation Form (see #1 above)
  6. Retirement Plan Rollover Application Form . Use this form to roll funds from another qualified, pre-tax plan into the Vanderbilt Retirement Plan. Your previous fund's administrator must complete part of this form. Read the instructions on the back of this form carefully. Other documents must be submitted with this form or it will be considered an incomplete application and will be returned to you. This form is not used to roll money OUT of the Vanderbilt Plan. Contact the company you invest with for those forms.
  7. 415(g) Aggregation Form. Use this form to report contributions to a retirement account other than Vanderbilt's, in order to comply with the Internal Revenue Code 415(g) limit on contributions. Consult with your tax advisor to ensure correct reporting of contributions.
  8. Retirement Plan Hardship Withdrawal Application . DUE TO INTERNAL REVENUE CODE CHANGES, PREVIOUS VERSIONS OF THIS FORM CANNOT BE ACCEPTED. Use this form to apply for a hardship withdrawal from your retirement account. See the Retirement Plan: Withdrawals and Distributions page of the HR website for information about Financial Hardship Withdrawals and the additional documentation required.
  9. Discontinue Vanderbilt Contributions to the Union Pension Plan. A staff member covered by the Collective Bargaining Unit (union) would use this form to discontinue Vanderbilt contributions to the Union Pension Plan so that he/she may enroll in the Vanderbilt University Retirement Plan.
 Benefits
Retirement Plan Summary Plan Description Benefits
Short-Term Disability Summary Plan Description Benefits
Summer Discount Form (.pdf) Benefits
Superior Vision Services Benefits
Superior Vision Services, Summary Plan Description Benefits
Superior Vision Services, Member Reimbursement Claim Form Benefits
Supplemental Life Insurance Drop Form Benefits
Tuition Benefit Listserv — Instructions for Signing Up Benefits
Tuition Benefit for My Child Benefits
Tuition Benefit for Myself or My Spouse/Partner Benefits
Additional Pay Form Employment
Employment Eligibility Verification (I-9) Employment
Employee Information Forms:
This form is to be used by NEW staff, faculty & students
This form is to be used by CURRENT/FORMER staff, faculty & students
 Employment
Employment Request to Review Personnel File Form Employment
Paycard Application Form Employment
Internal Consultant Payment Form Employment
Performance Evaluation – University Employment
Performance Evaluation (Leadership Model) – University Employment
Personnel Action Form (New Hire PAF) Employment
Personnel Action Form (Turnaround PAF)
Federal Centers
 Employment
Personnel Action Form - Distribution Form
Federal Centers
 Employment
Personnel Action Form (Turnaround PAF)
Non-Federal Centers
 Employment
Personnel Action Form - Distribution Form
Non-Federal Centers
 Employment
Position Description Questionnaire (PDQ) Employment
Position Description Questionnaire - EZ (PDQ-EZ) Employment
Position Management Form (PMF) Employment
Separation Process Checklist Employment
Reporting of Taxable Gifts, Awards, Prizes and Other “Perks” Employment
Summer Faculty Pay
  1. Instruction Sheet
  2. OCGA Summer Pay Reminders
  3. Summer Faculty Pay Form Fillable PDF Version
  4. Summer Faculty Pay Form
  5. Summer Faculty Pay Form (.xls) Excel Version
Employment
Stipend Request Form 2008(.doc) Employment
VUMC ID Authorization Form Employment
W-2 Replacement Request Form
How To Read Your W-2
W-2 Calculator 		Employment
Federal Tax Forms:
  • W-4 Form (Employee's Withholding Allowance)

 

State Tax Forms:
  1. A-4 Form (Alabama State Tax Withholding Allowance)
  2. DE-4 Form (California State Tax Withholding Allowance)
  3. CT-W-4 (Connecticut Tax Withholding Allowance)
  4. G-4 Form (Georgia State Tax Withholding Allowance)
  5. IL-W4 (Illinois Tax Withholding Allowance)
  6. IA-W4 (Iowa W-4)
  7. K-4 Form (Kentucky State Tax Withholding Allowance)
  8. K-4E form (Kentucky State Tax Withholding Allowance)       For Exemption
  9. L-4 (Louisiana Tax Withholding Allowance)
  10. L-4E (Louisiana Exemption from Withholding Louisiana Income Tax)
  11. MW-507 Form (Maryland State Tax Withholding Allowance)
  12. M-4 (Massachusetts Tax Withholding Allowance)
  13. Nebraska W-4
  14. N-J W4 Form (New Jersey State Tax Withholding Allowance)
  15. New Mexico W-4
  16. IT-2104 E (New York Non-withholding Form)
  17. IT-2104 (New York Tax Withholding Allowance)
  18. NC-4 (North Carolina Tax Withholding Allowance)
  19. IT-4 Form (Ohio State Tax Withholding Allowance)
  20. Oklahoma W-4
  21. REV-419 AS (Pennsylvania Non-Withholding Form
  22. RIW-4 (Rhode Island Tax Withholding Allowance)
  23. South Carolina W-4
  24. Utah W-4
  25. W-4VT (Vermont Tax Withholding Allowance)
  26. VA-4 Form (Virginia State Tax Withholding Allowance)
  27. D-4 Form (Washington D.C. Tax Withholding Allowance)
Employment
Non-FMLA Medical Leave FMLA
Alternative Work Arrangement Request Other
Check Replacement Request Form Other
Commodore Award Eligibility and Criteria Other
Commodore Award Nomination Form Other
Department Change Form Other
Electronic Communication Access Information Sheet Other

HR System Security Access Request Form

Human Resource System Security

Other
Payroll Check Distribution Authorization Form Other
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