Benefits At A Glance 2009 — Faculty

Benefits At A Glance 2009 — Staff and House Staff

Flexible Reimbursement Account (FRA), see "Health Reimbursement Account"

Flexible Spending Account (FSA)

[formerly Personal Spending Account (PSA)]

1. Claim Form
2. Eligible Expense List
3. Enrollment Form
4. Summary Plan Description

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. Summary Plan Description

Life and Accidental Death & Dismemberment Summary Plan Description

Open Enrollment Form for employees who have already submitted an online form and need to make changes on the last day of Open Enrollment. This form must be stamped received by a Benefits Office representative by 5:30 p.m. on October 15

• Fillable PDF version to complete on computer
• Blank PDF to print and complete by hand

Personal Spending Account, see"Flexible Spending Account"

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 Application for Supplemental (non-matched) Contributions
   If you are not yet eligible for Vanderbilt's match or you want to contribute on the supplemental level, use this application to open an account with TIAA-CREF.
4. TIAA-CREF Application for Matched Contributions
   If you are eligible for Vanderbilt's match, use this application to open an account with TIAA-CREF. If you want to contribute matched and non-matched funds to TIAA-CREF, you must complete both the "matched contributions" and "non-matched contributions" applications.
5. VALIC (formerly AIG Retirement) 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)
6. 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)
7. 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.
8. Internal Revenue Code 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.

Retirement Plan Financial Hardship Withdrawal Application

DUE TO INTERNAL REVENUE CODE CHANGES, PREVIOUS VERSIONS OF THIS FORM CANNOT BE ACCEPTED

VSP Vision Out-of-network Claim Form

Employment Eligibility Verification (I-9)

• I-9 Form (.pdf) UPDATED As of August, 25th 2009, the Form I-9 with the exp date of (08/31/2012) is the only version of the form that is valid for use revised "(08/07/09)N". You should have the latest version of the free Adobe Reader to download and use Form I-9. Please always download the Form I-9 as needed from the HR website.
• E-Verify Electronic I-9 Service Info 11/17/09
• I-9 Employer Handbook M-274 (revised 7/31/09)

Employee Information Forms:

• New Employee Information Form

This form is to be used by NEW staff, faculty & students

This form is to be used by CURRENT/FORMER staff, faculty & students

Paycard Application Form

• Adobe Acrobat (.pdf) file
• Microsoft Word (.doc) file

Department Retrieval Paycheck Form

• Adobe Acrobat (.pdf) file
• Excel (.xls) file

Performance Appraisal (University Exempt Staff) - Microsoft Word (.doc) file

For VUMC Performance Evaluation Information, click here.

Performance Appraisal (University Non-Exempt Staff - Microsoft Word (.doc) file

For VUMC Performance Evaluation Information, click here.

Performance Improvement Counseling (PIC) Form

• Adobe Acrobat (.pdf) file
• Microsoft Word (.doc) file

For information on the Performance Improvement Counseling Policy, click here.

Personnel Action Form (Turnaround PAF)

Federal Centers

Personnel Action Form - Distribution Form

Federal Centers

Personnel Action Form (Turnaround PAF)

Non-Federal Centers

Personnel Action Form - Distribution Form

Non-Federal Centers

Employment

Position Description Questionnaire (PDQ)

• Adobe Acrobat (.pdf) file
• Microsoft Word (.doc) file

Position Description Questionnaire - EZ (PDQ-EZ)

• Form - Adobe Acrobat (.pdf)
• Form - Microsoft World (.doc)
• Sample documentation (.pdf)
• Sample documentation (.doc)

Request for W-2 Replacement Form

• Adobe Acrobat (.pdf)

How To Read Your W-2

• Adobe Acrobat (.pdf)

Separation Process Checklist

• Adobe Acrobat (.pdf)
• Microsoft Word (.doc)

Reporting of Taxable Gifts, Awards, Prizes and Other “Perks”

• Taxable Fringe Reporting Form (.xls)
• Taxable Fringe Reporting Form (.pdf)

Federal Tax Forms:

• W-4 Form (Employee's Withholding Allowance)
• W-5 Form (Earned Income Credit)

State Tax Forms:

1. A-4 Form (Alabama State Tax Withholding Allowance)
2. EDD Form (California State Tax Withholding Allowance)
3. G-4 Form (Georgia State Tax Withholding Allowance)
4. K-4 Form (Kentucky State Tax Withholding Allowance)
5. K-4E form (Kentucky State Tax Withholding Allowance)       For Exemption
6. MW-507 Form (Maryland State Tax Withholding Allowance)
7. N-J W4 Form (New Jersey State Tax Withholding Allowance)
8. IT-4 Form (Ohio State Tax Withholding Allowance)
9. VA-4 Form (Virginia State Tax Withholding Allowance)
10. D-4 Form (Washington D.C. Tax Withholding Allowance)

FMLA Approval Letter for Chronic or Intermittent Leave

• Adobe Acrobat (.pdf)
• Microsoft Word (.doc)

FMLA Leave Request for Family Member's Medical Condition

• Microsoft Word (.doc)

FMLA Leave Request for Employee's Medical Condition

• Microsoft Word (.doc)

FMLA Leave Approval Letter

• Adobe Acrobat (.pdf)
• Microsoft Word (.doc)

FMLA Letter to be Used When Leave is not Approved

• Adobe Acrobat (.pdf)
• Microsoft Word (.doc)

FMLA Leave Approval Schedule to be Completed by Manager

• Adobe Acrobat (.pdf)
• Microsoft Word (.doc)

FMLA Notification of FMLA designation to be sent to Staff Member upon Leave Request

• Adobe Acrobat (.pdf)
• Microsoft Word (.doc)

FMLA Request to Return from Leave of Absence

• Adobe Acrobat (.pdf)
• Microsoft Word (.doc)

FMLA Staff Member Leave of Absence Request Letter

• Adobe Acrobat (.pdf)
• Microsoft Word (.doc)

Alternative Work Arrangement Request

• Microsoft Word (.doc)

Check Replacement Request Form

• Adobe Acrobat (.pdf)
• Microsoft Word (.doc)