Forms
This page links to forms used on a district wide basis.
Links to reference and/or supplemental material are provided whenever possible.
| Title |
Reference |
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| Application for Academic Degree Differential |
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| Application for Classified Degree Differential |
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| Employment Verification Request |
Tip Sheet |
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| Certification of Receipt of Unclassified Employee Handbook |
Unclassified Employee Handbook |
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| Harassment (Non-Sexual) Complaint Form R-901 |
Article 3E of AFT 1521A Agreement |
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| Expense Authorizations |
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| CalCard Forms |
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| Cardholder Statement of Questioned Item |
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| Change or Cancel Purchasing Card Account |
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Invoice Adjustment, Notification of
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| Missing Receipt |
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| Purchase Log |
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| Approving Official Request |
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| Purchasing Cardholder Agreement |
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| Request for Purchase Card |
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| Activity & Conference Forms |
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| Conference or Activity Attendance Request |
Reimbursement Procedure |
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| Conference Attendance, Report on |
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| Travel Advance, Request for |
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| Out of State Student Travel, Authorization/Notification of |
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| Mileage Expense Claim |
Mileage_Chart |
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| Travel Expense Claim |
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| Revolving Fund Reimbursement Request |
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| Tuition Reimbursement Forms (Non-Faculty) |
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Application for Tuition Reimbursement for Professional Development
Report of Completion Tuition Reimbursement for Professional Activity |
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| Paycheck (Salary Warrant) |
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| Application for Emergency Pay |
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| Warrant Recipient Designation (Beneficiary) |
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| Lost Warrant Affidavit |
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| Sabbatical Forms |
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| Sabbatical Leave Request - C143 |
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| Sabbatical Study Plan - C147 |
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| Sabbatical Independent Study Plan - C149 |
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| Sabbatical Travel Plan - C148 |
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| Salary Forms (Point Credit) for Faculty - See Article 31 of AFT Agreement |
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| Application for Certificate Differential - C247 |
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| Application for Point Credit Study in an Accredited College or University C153 |
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| Application for Point Credit Study in the Los Angeles Community College District C970 |
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| Request fo Approval of Point Credit Activity C242 |
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| Application for Point Credit for Specialized Study in an Advanced School Other than an Accredited College C158 |
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| Application for Point Credit for Study under Qualified Private Instructors C159 |
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| Statement of Educational Travel Completed C341A |
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| Educational Travel Report C341B |
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| Petition of Completion - Educational Travel C342 |
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| Proposed Itinerary for Educational Travel C684 |
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| Resignation and Retirement |
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| LACCD Forms |
|
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| Employee Exit Processing |
HR P-311 |
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| Resignation |
HR P-310 |
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| Service Credit Research, CalSTRS |
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| Service Credit Research, CalPERS |
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| Retirement System Forms |
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CalSTRS Cash Balance Benefit Program
(Elect Social Security or Remain in Cash Balance) |
LACCD Letter |
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| CalSTRS Cash Balance - Notification & Election |
Booklet
Opens link to CalSTRS |
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| CalSTRS Defined Benefit - Permissive Election |
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| Requests for Change |
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| Name Change Request |
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Address and Warrant(s) Recipient Designation
("Address Change") |
Tip Sheet |
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Change of Address, Classified Examinations
Opens link to Personnel Commission website. |
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Claim for Temporary Work Out of Classification
Opens link to Personnel Commission website. |
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Reinstatement (Classified Employee)
Opens link to Personnel Commission website. |
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| Transfer Request (Administrator) |
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Transfer Request (Classified Employee)
Opens link to Personnel Commission website. |
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| Transfer Request (Faculty) |
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| Temporary Transfer Request (Faculty) |
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| Time Reports, Work Schedules, and Leave of Absence Forms |
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| Absence Certification Request |
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| Unclassified Absence Certification Request |
Sick Leave Eligibility Bulletin |
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| Annual Physical / Eye Examination Certification |
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| Catastrophic Leave Donation |
HR W-301 |
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| Faculty Absence Report Partial Day (Fractional Day) |
HR W-210 |
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| Faculty Absence and Substitute Summary |
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| Leave of Absence Request |
Tip Sheet |
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| Retraining and Study Leave Request |
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| Formal Study Leave Request |
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| Independent Study Leave Request |
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| Attending Physician's Statement |
Tip Sheet |
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| Early Return Request |
Tip Sheet |
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| Overtime Request and Report |
Handbook |
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| Time Report: |
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| Department - Hourly Employees |
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| Salaried Exception 2019-20 |
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| Salaried - Exception: 2017-18 |
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| Salaried - Weekly Sign-In |
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| Partial Leave of Absence, Classified |
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| Voluntary Deduction Authorization Forms |
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| Charitable / Professional Organizations |
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U.S. Savings Bond
Not available at this time. |
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| Worker's Compensation |
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| Title |
Reference |
|---|
Employee Personnel File Checklists
New Hire (H-1000A)
In Service (H-1000B) |
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Volunteer-Intern Process Instruct. |
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Volunteer Forms
Application for Volunteer Services
Volunteer Report of Convictions |
HR R-331
Volunteer-Intern Process Instruct. |
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Performance Evaluations
References refer to applicable collective bargaining agreement or link indicated below. |
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Faculty, Basic and Comprehensive
Use form appropriate for assignment from collective bargaining agreement |
Appendix C |
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| Suggested Evaluation Plan Time Table & Worksheet - Comprehensive Evaluation of Tenured Faculty Member |
Page 187 |
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| Suggested Evaluation Plan Time Table & Worksheet - Tenure Review |
Page 191 |
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| All-Faculty - Sections A, C, and D |
Page 195 |
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| Classroom Faculty - Section B |
Page 197 |
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| Counselor - Section B |
Page 198 |
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| Librarian - Section B |
Page 199 |
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| ISA / Consulting Instruction - Section B |
Page 200 |
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| College Nurse - Section B |
Page 201 |
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| Disabilities Specialist / Instructor - Section B |
Page 202 |
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| Child Development Center Instructor - Section B |
Page 203 |
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Department Chair
CDC Director
Nursing Director |
Page 213 |
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Faculty, EOP&S
DSPS Director |
Page 217 |
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| Faculty Administrative Evaluations |
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| Classroom Faculty ADMINISTRATIVE Evaluation |
Page 204 |
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| Counseling Faculty ADMINISTRATIVE Evaluation |
Page 210 |
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| Library Faculty ADMINISTRATIVE Evaluation |
Page 207 |
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| Classified Staff Evaluations, AFT College Guild |
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| Probationary Employee |
Article 15; Appendix B |
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Permanent Employee
Prints on legal size paper. |
Article 16; Appendix C |
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| Other Classified Staff Evaluations |
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| Classified Staff, Local 99 |
Article 12 |
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| Classified Staff, Building Trades |
Article 15 |
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| Classified Staff, Local 721 |
Article 11 |
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| Classified Staff, Confidential |
PC Rule 702 |
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| Classified Staff, Management |
PC Rule 702 |
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| Academic Administrator/Supervisor Evaluations |
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| Academic Supervisor, Teamsters |
Article 8 |
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| Academic Administrators / Unrepresented |
Board Rule
10105.12 |
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College Presidents/Vice Chancellor
LACCD Self Assessment Instrument College President/Vice Chancellor
LACCD Data Collection College President/Vice Chancellor
LACCD Summary Evaluation of College President/Vice Chancellor |
Board Rule
10105.12
|
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Academic Vice Presidents
LACCD Self Assessment Instrument College Academic Vice President
LACCD Data Collection Instrument College Academic Vice President
LACCD Summary Evaluation of College Academic Vice President |
Board Rule
10105.12 |
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| Duty Statement, Academic Administrators, Teamsters |
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|
Classified Employees |
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|
Classified Employees |
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| Requests |
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| Academic Development Grant |
R-350 |
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| Academic Staffing Request |
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| Adjunct Provisional Equivalency |
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| Confidential Employee Status Checklist |
H-201 |
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|
Opens link to Personnel Commission website. |
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Opens link to Personnel Commission website. |
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| Equipment on Loan - Office Equipment |
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| Equipment on Loan - Technology |
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| Notification of Adjunct Faculty Selection |
HR R-130 |
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|
Opens link to Personnel Commission website. |
HR R-310 |
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| Restricted Hiring Form |
|
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| Acknowledgements and Waivers |
|---|
| 0.67 FTE Adjunct Instructor Limitation Request to Waive |
HR R-130
|
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| Acknowledgement of Employment Conditions, Specially Funded Programs (C1117) |
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| Employee Affidavit (W-11) |
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| Instructor, Special Assignment / Consulting Instructor Contract Provision |
HR R-121 |
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| PACE Contract Provision |
HR R-124 |
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| Worker's Compensation |
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| Employer's Report of Occupational Injury or Illness, AdminSure |
Reporting Occupational Injuries and Illnesses |
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| Incident / Injury Report, LACCD |
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| Referral for Treatment of Occupational Injury or Illness |
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| Supervisor's Report of Employee Injury or Illness, LACCD |
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