Flexible Spending Account Forms
• IntroductionThe 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.
Workers Compensation, LTD and Return to Work Forms
Request for Time
• Flexible Spending Account Spending FormsAll Flexible Spending Account forms are now available on the Civil Service Commission web page site.
• 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.
• 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.
• Change to Recall Form OSE-11 This form changes an employee's recall form. An employee can change locations and classifications for potential recall.
• 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 Health Insurance Assistance Application This form may be used by laid off Institutional Unit employees to obtain reimbursement for continuation of group 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.
• 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.)
• 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.