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Flexible Spending Account Forms
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.
Workers Compensation, LTD and Return to Work Forms
Request for Time
• Notice of Family and Medical Leave Form CS-1810
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.
• 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
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 Human Resource 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.
• 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.
• Annual Leave Donation Direct Transfer Form DMB-15-OSE (Rev. 6-2012)
This form is for use by employees where the applicable collective bargaining agreement or Civil Service Regulation authorizes direct transfer of annual leave. Only annual leave may be donated.
• Annual Leave Donation Bank - Donation Form DMB-16-OSE (Rev. 6-2012)
This form is for use by employees where the collective bargaining agreement or Civil Service Regulation authorizes an annual leave bank and all non-exclusively represented employees. Only annual leave may be donated.
• Request for Time from S & E, HSS, MCO, UAW or NEREs Annual Leave Banks DMB-18-OSE (Rev. 6-2012)
This form is to be used only by the S & E (H21), HSS (E-42), MCO (C-12), UAW (W-22 and W-41) as well as non-exclusively represented employees (NEREs) for requesting time from their respective 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.
• Nomination for Test Designated Status DMB-2200-OSE
This fillable 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.
• 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.
• 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 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.