To find publications, please visit our Publications page.
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.
- Some forms listed below may still bebranded as "DPA" forms.CalHR isupdating these forms as time permits.In the meantime, continue to usethe DPA forms.
You can also get standard forms from the DGS Forms Search website.
AffordableCare Act (ACA)
AffordableCare Act (ACA)Notification Checklist- CalHR782
Annual Leave
Annual Leave - Sick Leave/Vacation - Election Form CalHR 875
Arduous Work Pay Requests
Arduous Work Pay RequestForm - CalHR 777
Bicycle Commuter Program
- Bicycle Commuter Program Quarterly Self-Certification - CalHR 873
Cash Options
Consolidated Benefits (CoBen)
For excluded employees and eligible represented employees in bargaining units 2, 7, 8, 16, 17, 18, and 19.
FlexElect
For all other employees.
- Cash Option Enrollment Authorization - STD 701C
- CalPERS Health Benefits Enrollment Form - HBD-12-(Navigateto form on CalPERSweb site)
- Automated Dental Plan Enrollment Authorization - STD 692(redirect to Benefits Calculator)
CEA and Exempt Appointees - forms for Personnel Offices
- CEA Return Rights Worksheet - CalHR 769
- Exempt Return Rights Worksheet - CalHR 770
Confidential Designation Request
- Confidential Designation Request Form - CalHR 124
Criminal Record Supplemental Questionnaire
Dental
- Automated Dental Plan Enrollment Authorization - STD 692(redirect to Benefits Calculator)
- Dental Plan Direct Payment Authorization - STD 696
- Affidavit of Parent-Child Relationship - CalHR 025
- Affidavit for Domestic Partners Being Claimed as Economic Dependents - CalHR 680
Dental COBRA Forms
- COBRA Calendar
- COBRA Election Form- CalHR 767
- COBRA administrators can find Word versions of COBRA forms on HR Net.
Delegation
CEA Position Request - CalHR 881
Dependent Re-Verification
- Dependent Eligibility Checklist - CalHR 781
- Dependent Re-Verification (DRV) Appeals Intake Form - CalHR 277
Duty Statement
In order to access the Duty Statement template/sample, click the link, save the form to your computer, and open the form via Adobe Acrobat or Adobe Acrobat Reader. If you need assistance, contact PMD@calhr.ca.gov.
- Duty Statement Template - CalHR 874
- Sample Duty Statement Template - CalHR 874 Sample
EEOQuestionnaire
State Employee Race/Ethnicity Questionnaire for New Hires and Rehires -CalHR 1070
Employee Suggestion Program
For Employees/Suggesters
For Evaluators
Employee Wellness
- Healthier U Branding Policy and Approval - CalHR 145
Examination/Employment Application - STD 678
Minimum Qualifications Determination Tool- CalHR 511B
Family and Medical Leave Act (FMLA)
- Notice of Eligibility and Rights and Responsibilities - CalHR 752
- Designation Notice - CalHR 753
FlexElect Reimbursem*nt Accounts
- Reimbursem*nt Account Enrollment Authorization - STD 701R
- Premium Only Plan Request for Disenrollment -CalHR 006
- Flex Elect Reimbursem*nt Claim Form - CalHR 351
- Letter of Medical Necessity - ASI
- Qualified Reservist Distribution (QRD) Request Form -CalHR 902
Reimbursem*nt Accounts COBRA Forms
- COBRA Election Form -CalHR 689
COBRA administrators can find Word versions of COBRA forms on HR Net.
Grievances
- Employee Contract Grievance - STD 630
- Excluded Employee Grievance - STD 631
- Job Description Form -CalHR 651Note:Employees filingan out-of-class grievance shouldcompleteaJob Description Formand submit it to their personnel office along with their grievance form.
Group Legal Services Insurance Plan
- Group Legal Enrollment Authorization Form for Actives including full-time, part-time, and direct pay departments, Form #200849
- Group Legal Enrollment Authorization Form for Retirees, Form #200686
Hire Above Minimum
- Hire Above Minimum Request- CalHR 684
- Hire Above Minimum Request, Former Exempt Employee - CalHR 685
- Hire Above Minimum Request, Former LegislativeEmployee - CalHR 691
Layoff
Forms from Section 400 of the Layoff Manual
- Prior Exempt Service Questionnaire -CalHR 004
- Verification of State Service (Outside the Executive Branch) -CalHR 039
- Military Service Information -CalHR 190
- Verification of Total State Service -CalHR 690
- Military Campaign Service Qualification Flowchart|Military Service Qualification Worksheet - Text Only (RTF)
- Recognized Military Campaigns and Armed Forces Expeditionary Medals for California Seniority Credit| Recognized Military Campaigns and Armed Forces Expeditionary Medals for California Seniority Credit - Text Only (RTF)
- Exempt Handout for Employees | Exempt Handout for Employees - Text Only (RTF)
Forms from Section 700 of the Layoff Manual
- Layoff Plan and Request for Preliminary Seniority Scores - CalHR 009 Note:CalHR 009has been replaced by the online, electronic Layoff Tool. Do not use CalHR 009 form unless you have contacted your department's assigned CalHR Layoff Consultant about your layoff and you have been directed to use it.
- Notice of Involuntary Transfer, Demotion, or Termination -CalHR 015
- Report of Current Performance -CalHR 040
Forms from Section 900 of the Layoff Manual
Establishing Reemployment Lists -CalHR 016 | Instructions
Leave Management
- Leave Activity and Correction Certification - CalHR 139
- Leave Reduction Plan - CalHR 138
- 2021Department Certification of Funding and Participation - Excluded Employee Leave Buy-Back Program - CalHR 749
- 2021Department Certification of Funding and Participation - Vacation/Annual Leave Cash Out Program - CalHR 878
Medal of Valor
Governor's State Employee Medal of Valor Special Act / Special Service Award Nomination -CalHR 012
Merit Award
- Superior Accomplishment Gift or Cash Award Recommendation - STD 278
- Governor's State Employee Medal of Valor Special Act / Special Service Award Nomination -CalHR 012
Military Leave
- Military Leave Worksheet
- Certification of Qualifying Exigency for Military Family Leave (Family and Medical Leave Act) - CalHR 756
- Certification for Serious Injury or Illness of Covered Servicemember for Military Caregiver Leave - CalHR 757
Negri Award
Nomination form- CalHR 601
Partial Service Retirement
Partial Service Retirement Application -CalHR 062
Pre-tax Parking
- Pre-Tax Parking/Third-Party Administrator/Reimbursable Account Claim - CalHR 681
- Account Enrollment Form -CalHR 682
Retired Annuitant Certification
Retired Annuitant Self-Certification -CalHR 715
Retirement Designation Request
- State Safety Retirement Determination Questionnaire - CalHR 169
- Peace Officer/Firefighter (PO/FF) Retirement Determination Questionnaire - CalHR 170
- Retirement Designation Request - CalHR 619
Savings Plus
- Transfer Future Leave Accruals to Savings Plus - CalHR 271
- Financial Statements with IndependentAuditor's Report- Year Ending December 31, 2022
- Financial Statements with Independent Auditor's Report- Year Ending December 31, 2021
- Financial Statements with Independent Auditor's Report- Year Ending December 31, 2020
- Financial Statements with Independent Auditor's Report- Year Ending December 31, 2019
- Financial Statements with Independent Auditor's Report- Year Ending December 31, 2018
Seniority
Final Seniority Score Package - CalHR 700
State-owned Housing
- State-owned Housing Inspector Review - CalHR 165
Travel, Relocation, Reimbursem*nt
- Travel Expense Claim - STD 262
- Hotel/Motel Transient Occupancy Tax Waiver - STD 236
- Excess Lodging Rate Approval (with Attachment ) - STD 255C
- Out-of-State Travel Approval Request - STD 257
- Out-of-State Travel Approval Request (Trip Description) - STD 257C
- Blanket Approval for Out-of-State Travel - STD 260
- Authorization to Use Private Owned Vehicle on State Business - STD 261
- Insurance Verification & Authorization to Operate Privately Owned/Rented/Leased Aircraft on State Business - STD 265
Transfer Determination
TransferEligibility Worksheet - CalHR 880
Veterans'Preference
- Veterans' Preference for Examinations - CalHR 1093
- Veterans' Preference - Provisional Transfer Waiver - CalHR 1094
Vision Benefits
- Vision Plan Enrollment Authorization - STD 700
- Vision Plan Direct Payment Authorization - STD 703
- Dependent Eligibility Verification Checklist - CalHR 781
Vision COBRA Forms
- COBRA Calendar
- COBRA administrators can find Word versions of COBRA forms on HR Net.
Withhold
- Minimum Qualifications Withhold Determination Worksheet - CalHR 272
- For Cause Withhold Determination Worksheet - CalHR 267
Workers' Compensation
Industrial Disability Leave With Supplementation Benefits Information and Option Selection - STD 618S
Please visit our Publications page to get the Workers' Compensation Claim Kit.