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1156 High Street
Santa Cruz, CA 95064

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Maintained by shrweb@ucsc.edu
Last Revised: 08/09/2011

Staff HR Forms Library

Leaves of Absence Forms

Benefits Bridge Insurance Continuation - Unit 18 shr-1060.pdf
  UCSC Insurance Continuation Election Form, instructions, and rates for Unit 18 employees on Benefits Bridge.  
Catastrophic Leave Donation Flyer Sample shr-1110.doc
  Sample flyer used to call for donations of leave for an employee participating as a recepient in the catastrophic leave program. Also requires use of forms: Catastrophic Leave Recipient Application Catastrophic Leave Donor Form Catastrophic Leave Donor Roster Catastrophic Leave Service Center Worksheet. Also see Catastrophic Leave Donation Program Guidelines and Procedures.
 
Catastrophic Leave Donor Form shr-1100.pdf
  For use by an employee to donate vacation leave to another employee. Also requires use of forms: Catastrophic Leave Recipient Application Catastrophic Leave Donation Flyer Sample Catastrophic Leave Donor Roster Catastrophic Leave Service Center Worksheet. Also see Catastrophic Leave Donation Program Guidelines and Procedures.
 
Catastrophic Leave Donor Roster shr-1120.xls
  Roster for Catastrophic Leave Donations. Also requires use of forms: Catastrophic Leave Recipient Application Catastrophic Leave Donor Form Catastrophic Leave Donation Flyer Sample,   Catastrophic Leave Service Center Worksheet. Also see Catastrophic Leave Donation Program Guidelines and Procedures.
 
Catastrophic Leave Recipient Application shr-1090.pdf
  For use by a staff employee to request participation as a recipient in the UCSC Catastrophic Leave Donation Program. Also requires use of forms:  Catastrophic Leave Donor Form Catastrophic Leave Donation Flyer Sample Catastrophic Leave Donor Roster Catastrophic Leave Service Center Worksheet. Also see Catastrophic Leave Donation Program Guidelines and Procedures.
 
Catastrophic Leave Service Center Worksheet shr-1130.pdf
  Worksheet for Recipient's Service Center Administrator. Also requires use of forms: Catastrophic Leave Recipient Application Catastrophic Leave Donor Form Catastrophic Leave Donation Flyer Sample Catastrophic Leave Donor Roster. Also see Catastrophic Leave Donation Program Guidelines and Procedures.
 
COBRA Rates (Link)
  COBRA insurance continuation rates.
 
Family Medical Leave (FML) Guidelines, Notices, Certifications, & Forms (Link)
  UC resources for administering and requesting Family Medical Leave (FML).
 
Furlough or Temporary Layoff Insurance Continuation shr-1010.pdf
  UCSC Insurance Continuation Election Form, instructions, and rates for employees on furlough or temporary layoff.  
Furlough Notice shr-1070.doc
  Template for notice of furlough.  
Investigatory Leave Sample Notice shr-1080.doc
  Sample notice of an investigatory leave of absence to investigate an allegation.  
Layoff Notice Template - Indefinite (99) shr-1520.doc
  To inform an employee not covered under a collective bargaining agreement of their layoff.  
Layoff Notice Template - Indefinite (CX) shr-1528.doc
  To inform an employee of an indefinite layoff or reduction in time.  
Layoff Notice Template - Indefinite (EX) shr-1544.doc
  To inform an employee of an indefinite layoff or reduction in time.  
Layoff Notice Template - Indefinite (HX) shr-1536.doc
  To inform an employee of an indefinite layoff or reduction in time.  
Layoff Notice Template - Indefinite (K7)

shr-1548.doc

  To inform an employee of an indefinite layoff or reduction in time.  
Layoff Notice Template - Indefinite (NX) shr-1552.doc
  To inform an employee of an indefinite layoff or reduction in time.  
Layoff Notice Template - Indefinite (PA) shr-1556.doc
 

To inform an employee of an indefinite layoff or reduction in time.

 
Layoff Notice Template- Indefinite (RX/TX) shr-1532.doc
  To inform an employee of an indefinite layoff or reduction in time.  
Layoff Notice Template - Indefinite (SX) shr-1540.doc
  To inform an employee of an indefinite layoff or reduction in time.  
Layoff Notice Template - Probationary (99, CX, NX, and HX) shr-1524.doc
  To inform a probationary employee (99, CX, NX, and HX) of an indefinate layoff.  
Layoff Notice Template - Temporary Layoff (all staff) shr-1522.doc
 

To inform employees of their temporary layoff.

 
Layoff Notice Template - Temporary Layoff (limited) shr-1526.doc
  To inform a limited appointment employee not covered under a collective bargaining unit of their temporary layoff.  
Layoff Notice Template - Temporary Reduction in Time (all staff) shr-1523.doc
 

To inform employees of their temporary reduction in time.

 
Layoff Worksheet c17.pdf
  Layoff Worksheet  
Leave of Absence Request Form (Link)
  Form to request Leave of Absence. Also see Leave of Absence Guidelines and Procedures.
 
Leave With Pay Benefits Checklist (Link)
  This checklist explains how benefits are affected when on an approved leave of absence with pay (paid leave).  
Leave Without Pay Benefits Checklist (Link)
  This checklist explains how benefits are affected when on an approved leave of absence without pay.  
Leave Without Pay Insurance Continuation shr-1030.pdf
  UCSC Insurance Continuation Election Form, instructions, and rates for employees on leave without pay.  
Proof of Service Form shr-1370.pdf
  Fill out and attach with original and copies when proof of service or statement of delivery or mailing is required. Copies to appropriate files. (e.g., Notice of Intent)  
Supplement to Military Pay Worksheet (Link)
  Required when employees are called to active military duty while employed by the University; form helps determine if employee is eligible for military pay according to University policy and implementing guidelines. For more information, see Supplement to Military Pay Policies (UCOP).  
Unemployment Insurance Termination Report ucop-1062.pdf
  Unemployment Insurance Termination Report to be completed by the department(s) for all separating employees.  

Staff HR Procedures

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