LACCD - Faculty & Staff Resources: Resources Accessible From Any Computer

Bulletins & Calendars

Forms

Health Benefits

Intranet (District
Network Only)

Forms

This page links to forms used on a districtwide basis.

Employee Forms are used by individual employees to submit a request, etc.
Administrative Forms are used to initiate a business process or task.

Links to reference and/or supplemental material are provided whenever possible.

Employee Forms
Title			Reference
	Employment Verification Request		Tip Sheet
Expense Authorizations
	*CalCard Forms*
	Cardholder Statement of Questioned Item
	Change or Cancel Purchasing Card Account
	Invoice Adjustment, Notification of
	Missing Receipt
	Purchase Log
	Activity & Conference Forms
	Conference or Activity Attendance Request		Reimbursement Procedure
	Conference Attendance, Report on
	Travel Advance, Request for
	Out of State Student Travel, Authorization/Notification of			New!
	Mileage Expense Claim		Mileage_Chart	Updated!
	Travel Expense Claim			Updated!
	Revolving Fund Reimbursement Request
Paycheck (Salary Warrant)
	Application for Emergency Pay
	Warrant Recipient Designation (Beneficiary)
	Lost Warrant Affidavit
Salary Forms (Point Credit) for Faculty - See Article 31 of AFT Agreement
	Application for Certificate Differential - C247
	Application for Point Credit Study in an Accredited College or University C153
	Application for Point Credit Study in the Los Angeles Community College District C970
	Request fo Approval of Point Credit Activity C242
	Application for Point Credit for Specialized Study in an Advanced School Other than an Accredited College C158
	Application for Point Credit for Study under Qualified Private Instructors C159
	Statement of Educational Travel Completed C341A
	Educational Travel Report C341B
	Petition of Completion - Educational Travel C342
	Proposed Itenerary for Educational Travel C684
Resignation and Retirement
	*LACCD Forms*
	Resignation		HR P-310 Tip Sheet
	Application for Retiree Health Benefits		Tip Sheet
	Employee Exit Processing		HR P-311
	Service Credit Research, CalSTRS
	Service Credit Research, CalPERS
	Retirement System Forms
	CalSTRS Cash Balance Benefit Program (Elect Social Security or Remain in Cash Balance)		LACCD Letter
	CalSTRS Cash Balance - Notification & Election		Booklet Opens linkto CalSTRS
	CalSTRS Defined Benefit - Permissive Election
Requests for Change
	Address and Warrant(s) Recipient Designation ("Address Change")		Tip Sheet
	Change of Address, Classified Examinations Opens link to Personnel Commission website.
	Claim for Temporary Work Out of Classification Opens link to Personnel Commission website.
	Reinstatement (Classified Employee) Opens link to Personnel Commission website.
	Transfer Request (Classified Employee) Opens link to Personnel Commission website.
Time Reports, Work Schedules, and Leave of Absence Forms
	Absence Certification/Request		Tip Sheet
	Annual Physical / Eye Examination Certification
	Catastrophic Leave Donation		HR W-301
	Faculty Absence Report, Partial Day (Fractional Day)		HR W-210
	Faculty Absence and Substitute Summary
	Leave of Absence Request		Tip Sheet
		Attending Physician's Statement	Tip Sheet
		Early Return Request	Tip Sheet
	Overtime Request and Report		Handbook
	Time Report:
		Department - Hourly Employees
		Salaried - Exception: 2009-10	Handbook
		Salaried - Weekly Sign-In	Handbook
	Work Schedule: D / G Basis Employees		HR W-410
Voluntary Deduction Authorization Forms
	Charitable / Professional Organizations
	U.S. Savings Bond Not available at this time.
Worker's Compensation
	Statement of Employee's Pre-Designated Physician and Employee Consent For supervisor forms, see Administrative Forms section.		LACCD Worker's Compensation Program
Administrative Forms
Title			Reference
Performance Evaluations References refer to applicable collective bargaining agreement or link indicated below.
	Faculty, Basic and Comprehensive Copy form appropriate for assignment from collective bargaining agreement		Article 19 Article 42 Appendix C
	All-Faculty - Sections A, C, and D		Page 180
	Classroom Faculty - Section B		Page 182
	Counselor - Section B		Page 183
	Librarian - Section B		Page 189
	ISA / Consulting Instruction - Section B		Page 185
	College Nurse - Section B		Page 191
	Disabilities Specialist / Instructor		Page 192
	Child Development Center Instructor		Page 193
	Administrative Evaluation Classroom Faculty		Page 194
	Department Chair CDC Director Nursing Director		Page 197
	Faculty, EOP&S DSPS Director		Page 197
	Classified Staff, AFT College Guild		Article 16
	Probationary Employee Contact Personnel Commission		Page 31
	Permanent Employee Prints on legal size paper.		Page 31
	Classified Staff, Local 99		Article 12
	Classified Staff, Building Trades		Article 15	Updated!
	Classified Staff, Local 721		Article 11	Updated!
	Classified Staff, Confidential		PC Rule 702
	Classified Staff, Management		PC Rule 702	Updated!
	Academic Administrators, Teamsters		Article 8	Updated!
	Academic Administrators, Unrepresented		Board Rule 101005.12	Updated!
	College Vice Presidents		Board Rule 101005.12 PC Rule 702
	Outstanding Work Performance, Notice of Classified Employees			Updated!
	Unsatisfactory Services, Notice of Classified Employees			Link added!
Requests
	Academic Development Grant		R-350	Updated!
	Adjunct Provisional Equivalency
	Confidential Employee Status Checklist		H-201
	Community Representative Assignment Request Opens link to Personnel Commission website.
	Classified Staffing Request (C1121) Opens link to Personnel Commission website.
	Notification of Adjunct Faculty Selection		HR R-130
	Professional Expert Assignment Request Opens link to Personnel Commission website.		HR R-310
	Restricted Hiring Form			New!
Waivers
	0.6 FTE Adjunct Instructor Limitation Contract Provision		HR R-130 HR P-130
	Instructor, Special Assignment / Consulting Instructor Contract Provision		HR R-121
	PACE Contract Provision		HR R-124
Worker's Compensation
	Employer's Report of Occupational Injury or Illness, Southern California Risk Management Associates, Inc.		Reporting Occupational Injuries and Illnesses
	Incident / Injury Report, LACCD
	Referral for Treatment of Occupational Injury or Illness
	Supervisor's Report of Employee Injury or Illness, LACCD
	Worker's Compensation Claim Form & Notice of Potential Eligibility, State of California		LACCD Worker's Compensation Program

Last Update: 01/04/10ss