School Name

Human Resources

Department Name

Left Callouts

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


Benefit Forms
COVID Leave Request Form
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
Family Medical Employee's Physician Certification Form
Family Medical Leave Employee Family Member's Certification Form
Worker's Compensation Incident Report (No Medical Required)

New Employee
J-1 Visa for Visiting Scholars

Payroll Forms
Direct Deposit Authorization Form
Direct Deposit (Secondary) Form
Payroll Authorization Form for WebAdvisor
Payroll Deduction Authorization
Twelve Month Pay Authorization and Agreement

Timekeeping Forms
Non-Exempt Employees MonthlyTime Record
Time Record - Exempt Employees
Work-Study Time Record 
Extra-Help Overtime Record
Extra-Help Time Record
Overtime Approval Form
Overtime Record
Leave Request Form

General Forms
Accommodations Process for Faculty and Staff with Disabilities
Annual Report of Extra Income Over $500 Form
Classified Performance Evaluation Form
Classified Employee Performance Evaluation Plan
Concurrent Employment Form (Internal)
Employee Accommodation Request Form 
Notice of Termination
Grievance Form
Statement of Financial Interest (Rev. 12-2017)
Tuition Waiver Form - Spouse-Dependent