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Human Resources

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Human Resource Department
1200 North University Drive
Mail Slot 4942
Pine Bluff, AR 71601

Office #: 870.575.8400
Fax #: 870.575.4653/4658

Main Content

Forms

Benefit Forms

Medical Enrollment Form
Dental Enrollment Form
Vision Enrollment Form
Flexible Spending Account Enrollment Form
Flexible Spending Reimbursement Form
Group Benefits Enrollment Form
Group Benefits Change Form
Health Saving Plan Enrollment Form
Life Evidence of Insurability Form
Salary Deferral Agreement-UA
Retirement TIAA-CREF Beneficiary Change Form
Retirement Fidelity Investments Beneficiary Change Form
Pharmacy Appeal Form
Medical Appeal Form
Catastrophic Leave Form
Catastrophic Physician's Certification Form
Family Medical Leave Request Form

New Employee

W-9
J-1 Visa for Visiting Scholars

Payroll Forms
Direct Deposit Authorization Form
Direct Deposit (Secondary) Form
Payroll Deduction Authorization

General Forms
Accommodations Process for Faculty and Staff with Disabilities
Concurrent Employment Form (Internal)
Employee Accommodation Request Form
Grievance Form
Tuition Waiver Form - Spouse-Dependent

Physician Certification Forms
WH-380-Employee Physician Certification Form FMLA
WH-380-Family Member Physician Certification Form