• Introduction
The following are frequently requested forms distributed by the OSE. This listing gives a brief description of the form and instructions on how to receive a copy. Certain forms can be downloaded via Acrobat Reader and submitted individually. Others must be obtained from your personnel office or from the appropriate division in OSE. If you do not have Acrobat Reader on your computer, you can download the application from this site. This form listing is not exhaustive.

• Flexible Spending Account Spending Forms
All Flexible Spending Account forms are now available on the Department of Civil Service web page site.

• Institutional Unit Grievance Form OSE/U11-1
This is the statement of grievance form for Institutional Unit employees exclusively represented by the American Federation of State, County and Municipal Employees (AFSCME).

• Institutional Unit Grievance Appeal Form U11-2
This is the statement of appeal of grievance for Institutional Unit employees exclusively represented by the American Federation of State, County and Municipal Employees (AFSCME).

• Michigan State Employees Association - Employee Grievance Form DMB-19-OSE
This is the statement of grievance form for Labor and Trades employees exclusively represented by the Michigan State Employees Association (MSEA).

• Scientific and Engineering Unit Grievance Form
This is the statement of grievance form for Scientific and Engineering Unit employees exclusively represented by the Michigan Professional Employees Society (MPES).

• Technical Unit Grievance Form OSE/L32-1
This is the statement of grievance form for Technical Unit employees exclusively represented by the United Technical Employees Association (UTEA).

• Security Unit (MDOC) Grievance Form (C-12) 
This is the statement of grievance form for Security Unit employees exclusively represented by the Michigan Corrections Organization (MCO) in the Michigan Department of Corrections. Complete this form online and mail to MCO.

• Technical Unit Grievance Appeal Form OSE/L32-2
This is the statement of appeal of grievance for Technical Unit employees exclusively represented by the United Technical Employees Association (UTEA).

• UAW-Local 6000 Grievance Form OSE/UAW-1
This is the statement of grievance form for UAW represented employees in the Human Service and Administrative Support Units.

• UAW-Local 6000 Grievance Appeal Form OSE/UAW-2
This is the statement of appeal of grievance for Human Service and Administrative Support Unit employees exclusively represented by the UAW.

• UAW - Request for Release for UAW Grievance Investigation OSE-13
This form requesting release to investigate a grievance(s) as authorized by the UAW & State of Michigan contract, must be completed by the Chief Steward and approved by the appropriate supervisor before release is authorized.

• AFSCME & State of Michigan Health Insurance Assistance Application
This form may be used by laid off Institutional Unit employees to obtain reimbursement for continuation of grou health insurance premiums. See #11 and #12 in attached criteria. This form can be filled out on line and should be printed, signed and mailed to the Michigan AFSCME Council 25, 3625 Douglas Avenue, Kalamazoo, MI 49004-3403. Please keep a copy for your records.

• Application for Continuation of Insurances Application CS-1767 
Employees who go on a leave of absence, are separated, or laid off must fill out the this form within 60 days of the employees loss of coverage to have the opportunity to continue their benefits through COBRA. (Employees should request this form from their personnel office.)

• Benefit Election Form Instructions 
Human Resource Offices or employees can print this benefit instruction page for reference. It will provide information regarding the New Hire Benefit Election Form (ZB107) and help employees make or change benefit selections.

• Enrollment Application - Health, Vision, and Dental Care Plans CS-1777 
This form should be completed by employees with a qualifying event and newly hired or reinstated employees for the Health, Vision, Dental Care, Life and LTD insurance plans. This form should be returned to the employee's Human Resources office.

• Life Insurance and Accidental Duty Death Beneficiary Designation Change CS-1781 
This form should be completed by employees to change or add beneficiaries. This form must be returned to the employee's Human Resources office.

• Long Term Disability Application Form DMB-1696-OSE 
As a new employee or at open enrollment, this form must be submitted by employees requesting Long-Term Disability benefit coverage. The form is required to be sent to the employee's Human Resources office. Please keep a copy.

• Certification of Health Care Provider (FMLA) Form CS-1789 
This form should be completed by a health care provider when leave is being requested for your serious health condition, or to care for a seriously ill family member. The form must be completed and returned to your Human Resources office.

• FMLA Employee Request & Employer Response CS-1790 
This form should be used by the employee to request FMLA leave. This form should also be used to provide written notification of the Employer's response to an employee's request for FMLA leave or when it becomes clear to the supervisor that an employee's absence for a serious health condition is eligible for FMLA leave. The Employer/Department Representative is required to complete, sign and must either give or send a copy to the employee and the original to Human Resources. Please keep a copy.

• Verification of Dependent Eligibility CS-1771 
This form should be completed by employees who have eligible dependents between the ages of 19 to 25 to continue enrollment in State sponsored health, dental and/or vision insurance plans. The form should be returned to the employees Human Resource Office with the required documentation.

• Worker's Compensation Claim OSE-EHM Rev 4-2008 

• LTD Provider Attending Physician's Statement Rev 10-2005 

• Work Assessment DMB-OSE Rev 2-2006 

• Workers' Compensation First Check Release DMB-923 Rev 10-2002 

• Workers' Compensation First Check Process 

• Medical Release - Claimant Information Release Authorization DMB-OSE 2210 10-2005 

• Request for At Risk Assessment DMB-OSE 2209 Rev 2-2006

• Work Experience Agreement Form 
This form documents and clarifies the Work Experience Program's work arrangements and expectations between the employee and the on-site supervisor. The form is completed by the employee, the on-site supervisor and the vocational consultant and sent to the departmental case manager.

• Work Experience Supervisor Evaluation Form 
This form will be completed by the on-site supervisor on a weekly basis and used by the vocational consultant and case manager to review an employee's progress in the Work Experience Program. The form will be given to and collected from the on-site supervisor by the vocational consultant with a copy sent to the departmental case manager.

• Annual Leave Donation Direct Transfer Form DMB-15-OSE 
This form is for use by all bargaining units where the collective bargaining agreement authorizes direct transfer of annual leave. Only annual leave may be donated. Individual bargaining unit contracts and the civil service compensation plan should be referenced for eligibility requirements.

• Central Annual Leave Donation Bank - Donation Form DMB-16-OSE 
This form is for use by all bargaining units where the collective bargaining agreement authorizes a central annual leave bank and all non-exclusively represented employees. Only annual leave may be donated. Individual bargaining unit contracts and the civil service compensation plan should be referenced for eligibility requirements.

• Request for Time from UAW Central Annual Leave Bank DMB-17-OSE 
This form is to be used only by Administrative Support and Human Services bargaining unit employees for requesting time from the UAW central annual leave bank.

• Request for Time from Scientific & Engineering, Human Services Support Unit, or MSC/NERES Central Annual Leave Banks DMB-18-OSE 
This form is to be used only by the Scientific and Engineering Unit (H21), Human Services Support Unit (E-42), as well as non-exclusively represented Managerial, Supervisory, Confidential employees and Business and Administrative unit employees for requesting time from their respective central annual leave banks.

• School and Community Participation Leave Request Form DMB-14-OSE 
This form should be filled out by eligible employees requesting School and Community Participation Leave. School and Community Participation Leave is not to exceed 8 hours in a fiscal year. Request for time off is consistent with the procedures for requesting annual leave. Refer to applicable collective bargaining provisions or Civil Service Commission Regulations 5.09, Section C., for non-exclusively represented employees.

• Voluntary Work Schedule Adjustment Agreement 
This form should be filled out by eligible employees interested in participating in the Voluntary Work Schedule Adjustment program. Those eligible are non-exclusively represented employees, and employees in the Human Services Support, Scientific and Engineering, Labor and Trades, Safety and Regulatory, Administrative Support, Human Services, and Technical bargaining units. This form must be approved by the individual's immediate supervisor and the Appointing Authority of the Department.

• Temporary Employee Request Notice 
Executive Directive 2006-3 requires state departments utilizing temporary personal services workers to advise OSE of each assignment, and requires OSE to authorize use of temporary workers in assignments in excess of 480 hours. This worksheet can be used for notice and extension requests, and the completed form must be returned electronically to the Office of the State Employer.

• CS-1669 Response to Disability Accommodation Request 
The supervisor and the Reasonable Accommodation Coordinator use the form to formalize the accommodation, arrangements, expectations or denial. The form is signed by and distributed to the parties.

• Change to Recall Form OSE-11 
This form changes an employee's recall form. An employee can change locations and classifications for potential recall.

• CS-1668 Disability Accommodation Request by Employee 
Employees experiencing a disability that impacts on their ability to perform their job may complete this form. This form must be accompanied by medical certification from a health care provider and the State of Michigan Work Assessment Form outlining the employee's capabilities and limitations. Please keep a copy. See the Reasonable Accommodation Procedures.

• Employee Recall Form OSE-10 
This form should be filled out by employee going on layoff. The form indicates classification and location for potential recall.

• Nomination for Test Designated Status DMB-2200-OSE
This form is to be completed by departments when nominating positions for test-designated status under (1) the Omnibus Transportation Employee Testing Act (OTETA) for employees required to possess a CDL, (2) Civil Service Rule 2-7 for non-exclusively represented employees (NEREs) meeting Rule 2-7 criteria, and (3) Union Contract provisions for represented employees meeting applicable contract criteria.

• AFSCME & State of Michigan Tuition Reimbursement Application
This form is for Institutional Unit employees requesting reimbursement for tuition. This form can be filed out on line and should be printered, signed and mailed to Michigan AFSCME Council 25, 3625 Douglas Avenue, Kalamazoo, MI 49004-3403. Please keep a copy for your records.

• Professional Development Fund Reimbursement Application DMB-115-OSE 
This form is for non-exclusively represented employees requesting reimbursement from the Professional Development Fund. The form must be sent to the Office of the State Employer to seek reimbursement.

• Request for Contracting with Early Retirees (2002) DMB-941-OSE
This form is to be used for submitting requests for contracting with employees who retired under the special early out retirement program. Please refer to the September 3, 2002 memo on this subject from Janine M. Winters to Human Resource Directors for direction regarding contracting with retirees. OSE approval does not serve as the approval to contract. All Civil Service Rules and Regulations related to disbursements for Personal Services are still applicable.

• Request for Reimbursement - VDT/CRT Operator Corrective Glasses DMB-2212-OSE 
This form is to be completed by an employee who is requesting their Department to pay for a set of frames and lenses to be used with VDT/CRT screens. This form must be accompanied by a copy of the provider's bill and proof of payment (receipt, canceled check, etc.). An employee obtaining glasses for working on the VDT/CRT who does not otherwise wear glasses is not eligible for reimbursement. (Current rates for reimbursement.)

• Supervisor's Report of Reasonable Suspicion 
This form is to be completed to document the supervisor's observation prior to requiring an employee to submit to a reasonable suspicion drug or alcohol test.

• UAW Interdepartmental Transfer List Form 
This form should be completed by UAW Members for placement on the Interdepartmental Transfer List. This form must be returned to the employee's Personnel office.