HR, FMLA, and HIPPA Forms

A full range of HR resources to meet your needs.

HR Forms

FMLA Forms

  • Absentee Form: PDF | WORD

    This form includes sections to document information regarding an employee's attendance record and should be completed by an employee's supervisor. This form is simply used as an easy-reference tool to track an employee's attendance, including vacation and sick time used and available.

  • Counseling Session Memorandum: PDF | WORD

    This form is used to document conversations held between employer and employee where counseling has been provided for a problem in the work environment. This form is often used in conjunction with the Written Plan Memorandum and the Decision-Making Leave forms, as the first step in the disciplinary process. If an employee's behavior or performance does not improve after this documented conversation, a supervisor then meets with the employee, explains that concerns still exist, outlines the concerns, and asks the employee to write a plan to improve their performance and/or behavior. The Written Plan Memorandum (below) is used to document this conversation. If, after writing a written plan, an employee's behavior and/or performance still does not improve, the supervisor may choose to give the employee paid time off of work to decide whether or not they wish to stay employed with the organization. The Decision-Making Leave (see below) form is used to document this conversation. All forms referenced within this paragraph are to be signed by an employee and their supervisor and maintained in an employee's personnel file.

  • Decision Making Leave: PDF | WORD

    This form is to be used if an employee's written plan to improve their performance and/or behavior is not effective. It allows the employee a specified amount of paid time away from the job to decide whether they wish to continue their employment by making the requested improvements in their performance, or if they wish to terminate their employment. It includes: date of counseling session, reason for leave, date of leave, etc. This form is to be signed by the employee and the supervisor and maintained in the employee's personnel file.

  • Employment Application #1: PDF | WORD

    #1 This application form can be used by employers in the State of California who wish to collect full testing and background investigation releases.

     

    Please Note: P•A•S ASSOCIATES CONSULTS ON A NATION-WIDE BASIS.  PLEASE CONTACT OUR OFFICE TO OBTAIN AN EMPLOYMENT APPLICATION SPECIFIC TO YOUR STATE.

     

  • Employment Application #2: PDF | WORD

    #2 This application form can be used by religious non-profit employers in the State of California who wish to collect full testing and background investigation releases.   Religious non-profit organizations are exempted from sexual orientation anti-discrimination laws and are permitted to discriminate on the basis of religion only for jobs for which the practice of and belief in the religion of the organization is a legitimate, job-related requirement; and as long as the work involved is connected with carrying on the organization's religious activities.

     

    Please Note: P•A•S ASSOCIATES CONSULTS ON A NATION-WIDE BASIS.  PLEASE CONTACT OUR OFFICE TO OBTAIN AN EMPLOYMENT APPLICATION SPECIFIC TO YOUR STATE.

  • Employment Information Sheet: PDF | WORD

    This form is used to document all general information about an employee such as home address, phone number, social security number and persons to contact in case of an emergency. This form should be completed by the new employee with new hire paperwork and maintained in the employee's personnel file.

  • Employee Loan Form: PDF | WORD

    This form should be used whenever an employee requests and is granted a loan from their employer. This form will document the repayment terms of the loan, and is to be maintained in the employee's personnel file.

  • Employee Pay Advance: PDF | WORD

    This form should be used whenever an employee requests and is granted a pay advance from their employer, and should be maintained in the employee's personnel file.

  • Employee Probation Memorandum: PDF | WORD

    This form is used for those employees who have been given a written warning and whose performance and/or behavior has not improved, placing them on probation for a specific period of time. This form includes questions such as: reason for probation, means by which the supervisor will monitor progress during probation and steps employee must take to improve situation. This form is to be signed by the employee and the supervisor and maintained in the employee's personnel file.

  • Exit Interview Form: PDF | WORD

    This form is used for those employees whose employment is terminated (voluntarily or involuntarily).  It is maintained in the personnel file for easy reference of job and pay change history.  This form should be completed by an employee’s supervisor.

  • I-9 Form: PDF ONLY | I-9 Form Instructions: PDF ONLY

    This form includes several changes to the types of documents that can be accepted for purposes of determining identity and authorization to work.

  • Notice to Employee - Labor Code Section 2810.5: PDF | WORD

    Effective January 1, 2012, California Labor Code section 2810.5(a) requires that the following information be provided to each employee at the time of hire in the language the employer normally uses to communicate employment-related information.

  • Payroll Status Change: PDF | WORD

    This form is used to document job changes, pay changes, etc., and the reasons for those changes. It is maintained in the personnel file for easy reference of job and pay change history. This form should be completed by an employee's supervisor.

  • Performance Appraisal (2 Forms): PDF | WORD

    This form assists the supervisor in documenting all necessary information during an employee's performance appraisal. One form is provided for Non-Exempt and Part-Time employees and another for Exempt Employees. This form should be signed by an employee, their supervisor and the appropriate manager and maintained in the employee's personnel file for future reference.

  • Payroll Deduction Authorization: PDF | WORD

    This form is recommended for use by employers who allow employees to deduct amounts from their paychecks that are not required by law, i.e., health insurance premiums, merchandise purchases, etc.

  • Record of Conversation: PDF | WORD

    This form should be used whenever a supervisor has a conversation with an employee that needs to be documented. It can be used for employee situations or for general use within the daily operations of a business. If the use is for an employee situation, a copy should always be filed in the employee's personnel file.

  • Request to Make Up Time: PDF | WORD

    This form (or a form similar to it) is required when an employee wishes to request to take time off and make up the lost time within the same workweek, without incurring overtime. This form should be completed by an employee and approved by an employee's supervisor. The approval of make-up time is at the discretion of the supervisor.

  • Written Plan Memorandum: PDF | WORD

    This form is used for employees who need to make specific improvement in their performance, after the above-referenced counseling session has taken place and has proven to be ineffective. It identifies why a plan is to be developed, outlines how to make the improvement, the specific improvement that is expected, the date improvement is expected, how the supervisor will assist the employee, and the consequences if improvement is not attained.

  • Written Warning: PDF | WORD

    The verbal warning, written warning, and probation process is a second type of disciplinary action process. When using this more traditional form of disciplinary process, this form is to be completed by the supervisor and includes necessary documentation such as the reason for warning, improvement expected, and date improvement is expected. Both the employee and the supervisor should sign this form, which is to be maintained in an employee's personnel file.

  • Your Rights Under the  FMLA of 1993:

    PDF Only | CALIFORNIA Only PDF

    This form is a general description of an employee's rights under the FMLA of 1993 as amended January 16, 2009.

  • A Serious Health Condition: WORD Only

    This form explains the definition of a serious health condition with regard to FMLA leave.

  • Letter to Initiate FMLA/CFRA Leave: PDF | WORD

    This is a sample letter to employee to initiate FMLA/CFRA leave.  [For employers with 50 or more employees].

  • Letter to Initiate PDL/FMLA Leave: WORD Only

    This is a sample letter to employee to initiate PDL/FMLA leave.  [For employers with 50 or more employees].

  • Letter to Initiate CFRA Taken After PDL/FMLA Leave: PDF | WORD

    This is a sample letter to employee to initiate CFRA after the employee has utilized PDL/FMLA leave.  [For employers with 50 or more employees].

  • Letter to Initiate FMLA/CFRA Leave During Workers' Compensation: WORD Only

    This is a sample letter to employee to initiate FMLA/CFRA leave during a workers’ compensation leave.  [For employers with 50 or more employees].

  • Letter to Initiate PDL Leave: PDF | WORD

    This is a sample letter to employee to initiate PDL only.  [FMLA/CFRA do not apply if employer has less than 50 employees].

  • Letter to Initiate CFRA Leave: PDF | WORD

    This is a sample letter to employee to initiate CFRA leave to care for a registered domestic partner.  [For employers with 50 or more employees].

  • Letter to Initiate FMLA Leave – Qualifying Exigency: PDF | WORD

    This is a sample letter to employee to initiate FMLA leave for a qualifying exigency.  [For employers with 50 or more employees]

  • Letter to Initiate FMLA Leave – Servicemember: PDF | WORD

    This is a sample letter to employee to initiate FMLA leave to care for an ill or injured covered service member.  [For employers with 50 or more employees].

  • Request for Leave of Absence: PDF | WORD

    Employees use this form to request an FMLA leave.

  • Certification of HCP - Employee's or Family Member's Serious Health Condition - CALIFORNIA ONLY: PDF Only

    These forms can be supplied to an employee to obtain certification by their health care provider of a “serious health condition” for FMLA/CFRA leave.

  • Certification of HCP - (Employee) - FEDERAL ONLY: PDF ONLY | (Family Member) - FEDERAL ONLY: PDF Only

    These forms can be supplied to an employee to obtain certification by their health care provider of a “serious health condition” for FMLA/CFRA leave.

  • Leave of Absence Designation: PDF | WORD

    This form is used to designate to an employee the type of leave being utilized.

  • Certification of Qualifying Exigency for Military Family Leave: PDF Only

    This form can be supplied to an employee seeking FMLA leave due to a qualifying exigency.

  • Certification for Serious Injury or Illness of Servicemember: PDF Only

    This form can be supplied to an employee to obtain certification by the health care provider of service member.

  • FMLA Designation Notice: PDF Only | FMLAPDL Designation Notice: PDF Only

    These forms can be used to designate the amount of leave that will be counted against the employee’s FMLA or FMLA/PDLD leave entitlement.

  • Notice of Eligibility and Rights: PDF Only

    This form can be used to notify employees of their eligibility and rights and responsibilities under FMLA.

  • Description of HIPAA Forms: PDF | WORD

    This document explains the rest of the forms available below.

  • HIPAA Privacy Notice: PDF | WORD

    This document is a sample Privacy Notice for employers to review and customize for their organization. This notice also details the procedures employees are to follow to file a complaint. This notice is to be placed where all employees can view it on a daily basis.

  • Privacy Officer Job Description: PDF | WORD

    This document is a detailed job description outlining the official functions this individual should be performing on a daily basis. There is also verbiage that should be added to the Privacy Officer’s job description, as well as to any other individual’s job description that has access to protected health information.

  • Contact Person Provision Job Description Insert: PDF | WORD

    This provision may be inserted in the job description of the employee assigned the duties of contact person under the HIPAA Privacy Rule. In a small plan, this person will likely also be the privacy officer.

  • Individuals Whose Duties Include Access to Health Information: PDF | WORD

    This provision should be inserted in the job description of any employee who will have access to protected health information.

  • HIPAA Authorization to Disclose Health Information: PDF | WORD

    This document is to be completed when a covered entity must obtain an individual’s written authorization for any use or disclosure of protected health information that is not for treatment, payment or health care operations or otherwise permitted or required by the Privacy Rule. Examples of disclosures that would require an individual’s authorization includes disclosures to a life insurer for coverage purposes, disclosures to an employer of the results of a post-offer physical or lab test, or disclosures to a pharmaceutical firm for their own marketing purposes.

  • Business Associate Contract: PDF | WORD

    This contract is to be used when a covered entity uses a contractor or other non-workforce member to perform “business associate” services or activities. HIPAA requires that the covered entity include certain protections for the information in a business associate agreement/contract. This contract details specific written safeguards on the individually identifiable health information used or disclosed by its business associates.

  • US Department of Health and Human Services HIPAA Summary: PDF | WORD

    This pamphlet, created by the United States Department of Health and Human Services, is a summary of key elements of the Privacy Rule including those covered and what information is protected, as well as the use and disclosure of protected health information. Because it is an overview of the Privacy Rule, it does not address every detail of each provision, but does contain links to detailed guidance documents.

HIPAA Forms

P•A•S offers employers a trusted partnership that provides peace of mind by minimizing HR liability, enhancing team effectiveness, and promoting profitability.

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 (661) 631-2165 • Fax: (661) 631-2841

P•A•S Associates has expertise in human resources and other areas involving employment issues. P•A•S Associates, in providing this website, does not represent that it is acting as an attorney or that it is giving any form of legal advice or legal opinion. P•A•S Associates recommends that before making any decision pertaining to human resource issues or employment issues, including the utilization of information contained on this website, the advice of legal counsel to determine the legal ramifications of the use of any such information be obtained.

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