Forms/Exhibits Index

Forms may be accessed from this index. You may sort the table by Index, Title, Owner, Published, or Format by clicking on the table headings. Content displayed may be refined by using the column filters located underneath the column titles.

Listings of Retired Forms and Exhibits maybe be found in the disposition table.

Index Title
1-1 Departmental Payroll Voucher
1-2 Check Distribution
1-5A Monthly Employee Time Record
1-5B Hourly Employee Time Record
1-5C Weekly Employee Time Record
1-5D Weekly Exempt Time Record
1-6 Departmental Vacation/Holiday Payroll Voucher
1-7 Salary Spread Request
1-8A Authorization for Professional Services
1-8B Authorization for Professional Services (Less than $600)
1-8C Statement for Foreign National Honoraria Recipients
1-9 Payee Information Form
1-17 International Employees Only 
Request for GLACIER Password
1-18 Request for Taxpayer Identification Number and Certification for Prizes, Awards, and Research Participants
1-19 W-4 Employee's Withholding Allowance Certificate
1-23 Employee Change of Address
2-1 Request for New Cost Center
2-2 Custodian and Working Fund Authorization
2-5 Texas Sales and Use Tax Exemption Certification
2-5B Texas Sales and Use Tax Exemption Certification for
2-6 Payment Approval Voucher
2-7 Departmental Deposit
2-8 Restrictive Payee Stamp
2-9 Restrictive Endorsement Stamp
2-10 Daily Check Log
2-11 Cash Receipt
2-12 Cost Center and Project Statements Reconciliation & Acknowledgement
2-13 Direct Deposit Form
2-26 Justification and Pro Forma Budget
2-27 Initial Recharge Rate Request
2-45 Inventory Transaction Form
2-47 Removal of Equipment from University Campus
2-48 Work Request Form
2-49 Asset Information Form
2-50 Document Destruction Request Form
2-60 Application for Nurse Faculty Exemption
2-61 Application for Preceptor Exemption
2-62 Nurse Faculty Loan Form
2-63 Perkins Loan Repayment Form
2-65 Application for Tuition Exemption per TEC 54.208 Peace Officer Enrolled in Criminal Justice Course/s
2-67 Waiver Appeal
2-95 Texas Hotel Occupancy Tax Exemption Certificate
2-96 Non-Overnight Mileage Detailed Report
2-98 Official Occasion Expense Form
2-100 Travel/Non-Travel Expense Cover Sheet
2-104 Non Employee Expense Reimbursement
3-3 Personnel Action Form
3-5 Record of FLSA (Overtime) Compensation Time Earned and Taken
3-7 Form I-9, Employment Eligibility Verification
3-8 Notice of Voluntary Service
3-9 Criminal Background Check
3-15 Appeal of Disciplinary Action - First Step
3-15A Disciplinary Action Appeal - Continuation
3-16 Employee Clearance
3-18 Sick Leave Pool Application
3-19 Conflict of interest, Conflict of Commitment and Outside Activities
3-23 Request for Family and Medical Leave
3-24 Return to Work Release
3-26 High School Student - Position Information and Application
3-27A New Employee Packet
3-27B Instructions for Completing New Employment Paper Work
3-28 Employee Insurance Enrollment Application
3-30 Benefits Cost Worksheet
3-33 Coverage for Incapacitated Child Form
3-34 Medco Pharmacy Home Delivery Order Form (UT Select)
3-35 Medco Prescription Drug Claim Form (UT Select)
3-36 Transitional Benefits Form
3-37 UT Select Dental Claim Form
3-38 Superior Vision Provider Nomination
3-39 UT FLEX Claim Form
3-40 UT FLEX Direct Deposit Form
3-41 UT FLEX Letter of Medical Necessity
3-42 Fort Dearborn Term Life Beneficiary Designation
3-44 Notice of Creditable Coverage for Medicare Part D
3-45 TRS Form 6 (Notice of Final Deposit and Request for Refund)
3-46 TRS Form 18 (Request for Estimate of Retirement Benefits)
3-47 Transfer Verification Form
3-48 TRS Form 28 (Notice to Elect to Participate in Optional Retirement Program)
3-50 Authorization for Reduction for Employee Contributions
3-51 Authorization for Reduction for Employee Contributions for Employees returning to ORP
3-52 ORP Acknowledgement Form
3-53 Optional Retirement Program (ORP) Retirement Certification Form
3-54 Tax-Sheltered Annuity Disclosure
3-55 Purchase Change Agreement
3-56 Special Catch-Up Provision Disclosure
3-57 Short Term Disability Highlights
3-58 Long Term Care Brochure
3-59 Continuation Coverage Notice
3-60 HIPAA Privacy Information
3-61 Accidental Death and Dismemberment Benefits Guide
3-62 DeltaCare Benefits Guide
3-63 UT System Group Benefit Handbook for Employees
3-64 Group Term Life Benefits Guide
3-66 Long Term Disability Benefits Guide
3-67 Short Term Disability Benefits Guide
3-68 Superior Vision Benefits Guide
3-69 Teachers Retirement System (TRS) Handbook
3-70 UT FLEX Benefits Guide
3-71 UT Select Benefits Guide
3-72 UT Select Dental Benefits Guide
3-73 UT System Group Benefits Handbook for Retirees
3-74 UT System Retirement Programs Guide
3-75 Exit Interview Questionnaire
3-76 Quest Release Time Form
3-78 Classified Staff Evaluation Form - Narrative Format
3-79 Employee Self-Evaluation Form
3-80 Administrative and Professional Form
3-81 Classified Staff Evaluation Form - Check Box Format
3-82 Performance Management Forms
3-83 Performance Management Form for New Employees
3-84 Sample Reference Check Form
3-85 On-Campus Summer Camp / Conference Employment Application
3-86 Flexible Work Arrangement Agreement
3-87 Telecommuting Agreement
3-201 Personal Information Form
3-202 State Employment Verification Form
3-203 Selective Service Registration Verification Form
3-204 Sick Leave Pool Contribution Form
3-205 Financial Disclosure and Conflicts of Interest
3-206 Outstanding Maverick Award Nomination Form
3-207 Hiring Request Questions to Submit to Hiring Review Committee
4-4 Purchasing Card Carry Over Transaction Log and Example
4-5 Purchasing Card Transaction Log and Example
4-8 New Cardholder Account Form
4-10 Vendor Performance Form
4-11 Cardholder Agreement
4-16 Gift Certificate Expense Form
4-19 eShipGlobal Access Request Form
4-20 Vendor Direct Deposit / Advance Payment Notification Authorization
4-21 Vendor Supplier Information
4-21B Vendor Supplier Information Instructions
4-22 University Issued Cell Phone Request Form
4-23 Cell Phone Acceptance Form
4-24 Exclusive Acquisition Justification Form
5-4 Vehicle Request Form
5-5 Operation of UTA 15-Passenger Vans
6-1 GTA Parking Permit Decal Permission
6-3 Key Request
6-4 Lost or Missing University Inventory Report Form
6-5 Lost Property Report Form
7-1 Request to Host a Camp/Conference
7-3 Summer Conference Housing Reservation Request
7-4 Summer Conference Dining Request
7-6 Health Services Summer Camp Fee IDT
7-8 Advance Planning (Cosmic) Calendar Reservation Request
7-9 Department Event Request
7-11 Event Change/Cancellation
7-12 External Reservation Form
8-2 Supervisor's Report of Employee Work-Related Injury or Occupational Disease
8-6 Employee's Report of Work-Related Injury or Occupational Disease
8-9 Notification of Work-Related Injury or Occupational Disease
8-10A Injured Employee Workers Compensation Guidelines (English)
8-10B Injured Employee Workers Compensation Guidelines (Spanish)
8-10C Injured Employee Workers Compensation Guidelines (Vietnamese)
8-11 Supervisors Workers' Compensation Checklist
8-13 Ergonomic Evaluation Request
8-14 Workers’ Compensation Pharmacy Information
8-20A Workers' Compensation Network Acknowledgement (English)
8-20B Workers' Compensation Network Acknowledgement (Spanish)
8-20C Workers' Compensation Network Acknowledgement (Vietnamese)
8-21A Notice of Network Requirements for UT System (English)
8-21B Notice of Network Requirements for UT System (Spanish)
8-21C Notice of Network Requirements for UT System (Vietnamese)
8-26 Laboratory Safety Evaluation (Biological)
8-29 Hepatitis B Vaccine Waiver
8-30 Human Pathogen Registration (HPR)
8-31 Human Pathogen Registration Update (HPRU)
8-32 Verification of Training for Work with Vaccinia Virus and Other Orthopoxviruses
8-33 Autoclave Waste Treatment Log
8-34 Hepatitis B Vaccination/Hepatitis B Vaccine Waiver/Exemption
8-36 Laboratory Safety Evaluation
8-46 Hazard Reporting Form
8-56 Application for Copy of Driver Record
8-62 Charcoal and Propane Grill Permit
8-63 Tent Permit Request Form
8-64 Exchange of Lockout/Tagout Program
8-65 Energy Control Procedures
8-66 Lockout/Tagout Authorized Employee Form
8-70 First Aid Kit Request Form
8-71 IAQ Occupant Interview Form
8-72 Injury/Illness Reporting Form for Students & Visitors
8-73 Confined Spaces Entry Plan
8-74 Confined Spaces Inventory Form
8-75 Shop Safety Evaluation Checklist
8-77 Roof Access Request
8-81 Application to Use Radioactive Materials - sublicense
8-82 Request for Radiation Dosimeter Form
8-83 Request to Purchase Radioactive Materials Form
8-84A Radiation Safety Evaluation - Radioactive Materials
8-84B Radiation Safety Evaluation - Radiation-Producing Machines
8-84C Laser Safety Evaluation (Class 3b & 4 Lasers)
8-85 Pregnancy Declaration
8-86 Pregnancy Declaration Withdrawal
8-87 Biosafety Level 2 (BSL-2) Commissioning Checklist
8-88 Laser Registration Form
8-89 Radiation Producing Machine Registration (RPMR)
8-90 Consent for Minor in a Laboratory - Covered Activities
8-91 Authorization for Minors in Laboratories - Covered Activities
8-92 Laboratory Tour for Minors Notification Form
8-93 Consent for Minor in a Laboratory - Tours
8-94 Minors in Laboratories - Restriction Exception Request
8-102 CEMS Inventory Discrepancy
8-103 Chemical Donation Approval Request
8-104 Biological Indicator Test Results Log
9-1A Report of Medical History and Health Evaluation
9-2 Financial Policy
9-3 Authorization to Treat Minors
9-4 Consent for Treatment of a Minor Who Does Not Have Legal Power to Consent
9-5 Notice of Privacy Practices
9-7 Authorization for the Use and Disclosure of Protected Health Information
9-8 Authorization for the Use and Disclosure of Protected Health Information to Outside Entity
12-1 Guest Apartment Reservation Request
13-1 Faculty or Staff Organization Registration
13-4 Procedure Template
13-5 Forms and Exhibits Template
13-6 Records Disposition Log
13-7 Request for Authority to Dispose of Unscheduled University Records
13-8 Records Retention Schedule Departmental Records Amendment
13-9 Preliminary Summary Report of Tort Claims and Possible Tort Claims
13-10 Records Retention Recertification and Survey
14-1 Photographic Consent and Release Form
15-10 Alcoholic Beverage Request Form
15-13 Release and Indemnification Agreement for Minors
15-15 Release and Indemnification Agreement for Adult Students
15-16 Release and Indemnification Agreement for Adults
15-17 Food Waiver Request Application
18-1 Computing Device Encryption Exception Request
18-2 Information Resource Vulnerability Risk Acceptance Form
18-4 Server Management Policy (HOP ADM 5-602) Exception Form
19-1 Server Hosting Service Level Agreement
19-2 Emergency Computer Request Form
20-1 Gift Record Form
20-2 UT Arlington Payroll Deduction Gift Form
20-3 Craig H. Neilsen Foundation Scholarship for Students with Spinal Cord Injury
20-4 Deed of Gift
21-1 Request for Disbursement of Scholarship/Fellowship Award
21-2 Scholarship Committee Chair
22-1 Complaint Form
22-2 Request to Initiate H-1B
22-3 H-1 Foreign Employee Questionnaire
22-4 Departmental Request to Initiate Legal Permanent Resident
23-1 Life Safety Addendum
23-4 Roommate Agreement
23-5 Transfer Application Packet
23-7 Carpet Evaluation Request
23-8 Cleaning and Sanitation Inspection
23-9 Lease Assumption Application Packet
23-11 Occupant Termination Notice
24-1 Handbook of Operating Procedures Policy Template Format Guidelines
25-1 Consent to Obtain Medical Treatment for Minor Child
26-1 Campus Program Employee Listing
27-1 Campus Event Planning Sheet (CEPS)
27-2 Posting Form
27-3 Student/Group Travel Form
27-4 Student Organization Alcohol Addendum
28-1 Public Information Request