FREQUENTLY USED FORMS
EB 1054 HEALTH BENEFITS
TRANSMITTAL (used to notify health insurance carrier
of SLOAC, FMLA,
termination, reinstatement, change of title or address or
that require an explanation.
ERB 97 HEALTH BENEFITS APPLICATION (used
for application for health
insurance benefits for new employees,
reinstatement, retirement, change
optional benefits, change of spouse,
domestic partner, dependent children.
This requires documentation such as
verified copies of marriage or domestic
partner certificate, birth
FINAL ENTITLEMENT FORM - This must be submitted for every
employee who is
removed from payroll: i.e., resignation, leave of absence
FMLA FAMILY MEDICAL LEAVE ACT - You must
have been on payroll for 12 months
(full time) before eligible to receive up
to 12 weeks leave of absence.
OP 40 APPLICATION FOR RETIREMENT LEAVE OF
ABSENCE (Terminal Leave)
Pedagogues are eligible to apply for this. The form
must be filed 30 days
in advance of the leave and can only cover one term.
The ratio is one-half
of sick leave balance.
OP 44 APPLICATION FOR
TERMINATION PAY (used for the employee to receive
termination pay on the
basis of one-half of the unused sick leave accumulated
in the CAR. Maximum
days allowed in CAR is 200 days for appointees and 120 days for regular
an OP 44 Form
OP 85 PERSONNEL CHANGE FORM (for changes in name,
address, tax status)
OP 160 APPLICATION FOR LEAVE OF ABSENCE WITHOUT PAY
OP 198 APPLICATION FOR EXCUSE OF ABSENCE FOR PERSONAL ILLNESS AND
OP 198AR APPLICATION FOR BORROWED SICK LEAVE
OP 201 APPLICATION FOR EXCUSE OF ABSENCE WITHOUT PAY AND/OR
OP 221 APPLICATION TO ATTEND SCHOOL MEETING OR CONVENTION
OUTSIDE NEW YORK CITY
OP 255 - RESUMPTION OF SERVICE Form - used when an
employee is returning from a
leave of absence without pay
CONFIDENTIAL MEDICAL REPORT AND MEDICAL EVALUATION - Used for excuse
absence for more than 20 days, excuse of absence for alleged line of duty
sabbatical leave for restoration of health, leave of absence
without pay for
restoration of health. See instructions on this form for
other forms required in
conjunction with the above.
SALARY DIFFERENTIAL - (for additional education credits)
submit an application for a differential may file within a
six month period*
from the date of appointment or placement on payroll as a
or completion of coursework in order to receive
retroactive payment from
date of eligibility. Late filing results in loss of
money because the
effective date will be the first day of the month following receipt
application. (See Personnel Memo No. 14, 1999-2000). It is strongly
recommended that this form be delivered in person and that you get a
Keep copies of everything for your own records.
FOR SALARY STEP PLACEMENT- This form must be filed by the
pedagogue who is
newly appointed, whether claiming prior experience or not.
It also may be
filed by substitute personnel who want to receive salary
allowable prior outside experience related to the license. In
receive credit retroactive to the date of appointment or placement
payroll as a regular substitute you may file within a six month period
*after the qualifying event in order to receive retroactive payment.
Late filing results in loss of money because the effective date will be the
first day of the month following receipt of the application.
Personnel Memo No. 14, 1999-2000). It is strongly recommended that
be delivered in person and that you get a receipt. Keep copies of
for your own records.
* Effective 9/1/99
UFT Welfare Fund forms:
Contact UFT Welfare Fund at 212-539-0590 or check
the web site at
If you need a small supply of some of
these forms send your request to
UFTSecy@aol.com. Make sure to include your
name and school address.