1. Human Resources
1.1. Benefits
1.1.1. HIPAA Privacy Notice


Health Insurance Portability and Accountability Act

HIPAA Privacy Notice 


1.1.2. Change of Residential College


Change of Residential College for Faculty and Professional Staff (docx)

 

1.1.3. Family Medical Leave Act (FMLA)

Certification of Healthcare Provider for Employee's Serious Health Condition Form (PDF)

Certification of Healthcare Provider for Family Member's Serious Health Condition Form (PDF)

Certification of Qualifying Exigency for Military Family Leave (PDF)

Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave (PDF)

Designation Notice (PDF)

Employer Response to Employee Request for Family and Medical Leave (PDF)

Request for FMLA Leave (PDF)





1.1.4. Racer Wellness Savings

The Racer Wellness Savings Plan allows full-time regular employees the opportunity to receive a discount off of their monthly premiums. Please click on the link below for more details. 

 

 

Racer Wellness Savings Plan Policies

 

1.1.5. Salary Reduction Agreement Form

Salary Reduction Agreement Form (PDF)

1.1.6. Sick Leave Bank

Sick Leave Bank Member Request Form (PDF)

Sick Leave Bank Enrollment Form (PDF)

Sick Leave Bank Discontinuation Form (PDF)

Health Care Provider's Certification Form (PDF)

 

1.1.7. Tuition Waivers

Murray State Tuition Waivers


MSU Tuition Waiver Form 2017-2018 (PDF)
MSU Tuition Waiver Form 2016-2017 (PDF)

This tuition waiver is to be used by Murray State University employees taking courses at Murray State University.  This form MUST be approved by HR and the Bursar’s Office on or before the last day to drop/add the class requested

 

 

HEA 189 Waiver Form (PDF)

State Tuition Waiver Form (PDF)
To be used by non-Murray State employees of Kentucky post-secondary institutions for waiver of tuition on courses taken at Murray State. 


State Tuition Waivers

Western Kentucky Unviversity Tuition Waiver Form (PDF)
Employment certification form for MSU employees taking classes at Western Kentucky University. 

Kentucky Community & Technical College System (KCTCS) (PDF)
Employment Certification Form from Murray State employees taking classes through KCTCS. 

Eastern Kentucky University Tuition Waiver Form (PDF)

Employment Certification Form for Murray State employees taking classes at Eastern Kentucky University. 

University of Kentucky (UK) Tuition Waiver Form (PDF)
Employment Certification form for MSU employees taking classes at the University of Kentucky. 

CPE Tuition Waiver Form (PDF)
To be used by supervising and resource teachers for waiver of tuition for courses at Murray State University. The completed form should be returned to Teacher Education Services. 

Kentucky Tuition Waiver for Veterans


Tuition Waiver FAQs

Tuition Waiver FAQs - State Waivers

Tuition Waiver FAQs - HEA 189







1.1.8. Workers' Compensation Forms and Information


First Report of Injury Instructions

When an employee notifies you that an injury has occurred, it is your department’s responsibility to obtain all pertinent information needed for completion of the injury report (IA-1 form).


1) First Report of Injury or Illness Form
(email chixon@murraystate.edu in word format without social security number)

2) Fraudulent Claim Acknowledgement (Scan or fax to 3464 HR with employee/student worker signature)

3) Medical Waiver and Consent Form (Scan or fax to 3464 HR with employee/student worker signature)

4) Send form with employee/student worker to healthcare provider: Report of Medical Status

Complete the first report of injury or illness form immediately and e-mail it to Courtney Hixon chixon@murraystate.edu. If the injury occurs during the second or third shift or on the weekend, the injury must be reported at the beginning of the next working day. A delay in reporting an injury has the potential for denial of coverage by the Workers’ Compensation Branch.

First Report of Injury or Illness Form (IA-1) – All questions, except employee’s social security number, beginning with the section entitled “Employee/Wage” must be answered except those marked N/A. All questions relating to the accident must have detailed answers. Under "Initial Treatment" please choose the correct number. Minor Clinic Hospital is the same as a doctor’s office visit.

Also, note that the injured employee MUST sign the Fraudulent Claim/state information sheet. The employee’s signature certifies that the employee has read the paragraph about Kentucky law and understands that filing a fraudulent claim is a crime. The Medical Waiver and Consent form must also be completed.

It is very important that the above information and other related information (medical bills, disability statements, doctors’ reports, etc.) be submitted quickly to avoid denial of workers’ compensation benefits.

We appreciate your assistance in helping us process workers’ compensation claims. If you have any questions concerning these procedures or forms, please call Human Resources at 2146.

 

Additional Forms: 

Commonwealth of Kentucky - CCMSI, Inc - Report of Medical Status (PDF)

Fraudulent Claim Acknowledgement (PDF)

Lost Time and Return to Work Form (WCF-1) (doc)

Medical Waiver and Consent Form (PDF)

Notice of Designated Physician Form (PDF)

Notice of Second Designated Physician Form (PDF)

OSHA Reporting Requirement Update 1-1-15 (PDF) 

Provider Introductory Letter (PDF)

Request for Payment for Services or Reimbursement for Compensable Services (PDF)

Workers' Compensation Prescription Program Form (PDF)

Workers' Compensation Sick Leave Form (PDF)


1.2. Employment
1.2.1. Acknowledgement of University Non-Discrimination Policies

  

 

Acknowledgement of University Non-Discrimination Policies
(PDF)

1.2.2. Clearance Record Form

Each employee terminating his/her employment at Murray State University must meet with Human Resources and present this completed Clearance Form (PDF) prior to receiving his/her final salary payment.

1.2.3. Employee Disciplinary Report Form

Employee Disciplinary Report Form (PDF)

1.2.4. Ethics Policy Acknowledgement Form

Ethics Policy Acknowledgement Form (PDF)

1.2.5. Extra Compensation Form

Extra Compensation Form (PDF)

1.2.6. Handbook and Personnel Policies & Procedures Manual Acknowledgement

Handbook and Personnel Policies and Procedures Manual Acknowledgement (PDF)

1.2.7. Hiring Process
1.2.7.1. Adjunct Employment

ADJUNCT HIRING EMPLOYEE PACKET

This quick guide includes the information that the academic chair or hiring supervisor will need to begin the adjunct employment process. The academic chair or hiring supervisor will need to have the adjunct employee complete the following forms, which are included in the Instructions for the Adjunct Employees packet:

  • Sexual Harassment Awareness and Staff Handbook Acknowledgement Form
  • Statement of Ethical Principles and Code of Conduct Acknowledgement Form
  • Background Investigation Consent Form

All original forms need to be submitted to Human Resources prior to the first day of work. Failure to complete forms in a timely manner could result ina delay of employment and/or pay.

Returning adjunct employees with a break in service:

  • Background checks are not needed if the break in service is less than 12 months. If the break in service exceeds 12 months, a new background check must be completed prior to the first day of work.
  • All I9 forms are processed by Human Resources. New adjunct employees should contact Human Resources on or before their first day of work to complete the form. If the employee is returning to work after a break in service, please contact Human Resources to determine if a new I9 form needs to be completed.
  • The academic chair or hiring supervisor will need to complete the Network Resource Request Form and submit the form to Information Systems.

All new and returning adjunct employees who have not completed the mandatory Title IX Harassment Prevention Training will need to do so. Please visit the Support Site for instructions on how to access the training.

If you have any questions concerning this process, please call HR Employment Staff at 270.809.2146 or email msu.hr@murraystate.edu.

 

1.2.7.2. Exempt Staff
1.2.7.2.1. Request to Fill Exempt
Request to Fill Exempt
1.2.7.2.2. Authorization to Interview
Authorization to Interview
1.2.7.2.3. Search Committee Guidelines Acknowledgement Form
Search Committee Guidelines Acknowledgement Form
1.2.7.2.4. Recommendation to Extend an Offer of Employment
Recommendation to Extend an Offer of Employment
1.2.7.3. Faculty
1.2.7.3.1. Request to Fill Faculty
Request to Fill Faculty 
1.2.7.3.2. Authorization to Interview
Authorization to Interview
1.2.7.3.3. Search Committee Guidelines Acknowledgement Form
Search Committee Guidelines Acknowledgement Form
1.2.7.3.4. Recommendation to Extend an Offer of Employment
Recommendation to Extend an Offer of Employment
1.2.7.4. Non-Exempt Staff
1.2.7.4.1. Request to Fill a Non-Exempt Position Form
Request to Fill a Non-Exempt Position Form (Updated September 2016) (PDF)
1.2.7.4.2. Non-Exempt Search Committee Guidelines Acknowledgement Form
Non- Exempt Search Committee Guidelines Acknowledgement Form (pdf)
1.2.7.4.3. Employment Summary Form for Non-Exempt Positions
Employment Summary Form for Non-Exempt Positions (PDF)
1.2.7.4.4. Starting Pay Proposal Form
The Starting Pay Approval Form (PDF) is to be completed and fully approved before an offer of employment is made to a person who may be paid above the sub-minimum of the job's pay grade.  Any proposed amount above the Control Point must be approved by the Director of HR.
1.2.7.5. Temporary Employment

TEMPORARY HIRING EMPLOYEE PACKET

This quick guide includes the information that the hiring supervisor will need to begin the temporary employment process. The hiring supervisor will need to have the temporary employee complete the following forms, which are included in the Instructions for the Temporary Employees packet:

  • Sexual Harassment Awareness and Staff Handbook Acknowledgement Form,
  • Statement of Ethical Principles and Code of Conduct Acknowledgement Form
  • Background Investigation Consent Form.

All original forms need to be submitted to Human Resources prior to the first day of work. Failure to complete forms in a timely manner could result in a delay of employment and/or pay.

Returning temporary employees with a break in service:

  • Background checks are not needed if the break in service is less than 12 months. If the break in service exceeds 12 months, a new background check must be completed prior to the first day of work.
  • All I9 forms are processed by Human Resources. New temporary employees should contact Human Resources on or before their first day of work to complete the form. If the employee is returning to work after a break in service, please contact Human Resources to determine if a new I9 form needs to be completed.
  • The hiring supervisor will need to complete the Network Resource Request Form and submit the form to Information Systems.

All new and returning temporary employees who have not completed the mandatory Title IX Harassment Prevention Training will need to do so. Please visit the Support Site for instructions on how to access the training.

If you have any questions concerning this process, please call HR Employment Staff at 270.809.2146 or email msu.hr@murraystate.edu

1.2.7.6. Authorization of Background Investigation

Click to view the Background Check Form   (PDF)

1.2.8. I-9
UPDATE: On September 18, 2017 USCIS released a revised version of Form I-9, Employment Eligibility Verification. 


Please access the most current I-9 below:
 

Form I-9 (must be printed and completed on paper)  

Form I-9 (form fillable may not open with all browsers) 

Newly hired employees should come to Human Resources (4th floor Sparks Hall) to complete Form I-9 and to present their original documents.  Form I-9 is used for verifying the identity and employment authorization of individuals hired for employment in the United States.  All U.S. employers must ensure proper completion of Form I-9 for each individual they hire for employment in the United States.  This includes citizens and non-citizens. 

Employee must complete section 1 on or before the first day of work.  

Form I-9, Employment Eligibility Verification - Section One video 

 

Human Resources will complete and verify section 2 no later than 3 business days from the first day of work.  The employee must present unexpired original documentation that shows the employer their identity and employment authorization. For additional information on acceptable documents, please see the list of acceptable documents or review website.   


 


 

1.2.9. Independent Contractor or Employee Status

Revised forms as of 03.25.15

Independent Contractor or Employee Status - This form helps in determining the status in accordance with IRS for individuals performing services for Murray State. These questions are intended as a guide in making this classification, but sometimes further evaluation may be necessary.   

Independent Contractor or Employee Status (PDF) 

Independent_Contractor_Employee_Status_Multiple_Person_Request_Page2 (PDF)

Independent_Contractor_Employee Status_Groups_Usually_Paid_As (PDF)

1.2.10. Job Audit Questionnaire Form

Revised on 07/01/2016.  Due date to be determined.  To populate boxes on the form, double-click.  

Job Audit Questionnaire (doc) 


1.2.11. Personal Leave Form

Personal Leave Form (PDF)

1.2.12. Personnel Action (PA) Form
Personnel Action (PA) Form (PDF)
1.2.13. Summer Extra Compensation Form

Summer Extra Compensation Form (PDF)

1.2.14. Volunteer Forms

Volunteer Form (PDF)

1.2.15. Whistleblower Program Acknowledgement

The Whistleblower guidelines appear in section C in the Statement of Ethical Principles and Code of Conduct.

Whistleblower Program Acknowledgement Form (PDF)

 

1.3. Employee Change of Address Form

Employee Change of Address Form

This form can be submitted to HR by email msu.hr@murraystate.edu or faxed to 270.809.3464. 

1.4. Departmental Query Request form for HR/Payroll Access

The Departmental Query Request Form for HR/Payroll Access (PDF) is completed when an employee needs to view HR/Payroll data available for all employees assigned to specific ORG codes. The requesting person knows the confidential nature of the information they are requesting to view and agrees by signature to not in any manner, directly or indirectly, make known any confidential information to anyone or permit any person(s) to have access to confidential information that is not authorized.

The form is completed and sent to the Payroll office. 

Please call 270-809-4129 with any questions regarding this request form.

 

Click to open the Departmental Query Request Form for HR/Payroll Access.

1.5. Legal Name Change Procedures
Effective August 1, 2016

Faculty and Staff Legal Name Change Procedures  (pdf)

1.6. Performance Appraisals


Annual Performance Appraisal Instructions (PDF)

Exempt Performance Appraisal Form (PDF) 

Non-Exempt Performance Appraisal Form (PDF)

Appraisal forms have been distributed to Department Heads.  The deadline for all completed forms is Friday, April 7, 2017.  

Please contact Haley Stedelin (ext. 3094) or Courtney Hixon (ext. 2156) with any questions.    

 

 

 


1.7. Preferred First Name Change Request

Murray State University recognizes that faculty and staff may wish to use a name other than their legal name. When requested, the university will use a preferred first name on certain documents and online information sources. Employees may not designate a preferred last name. The official/legal name will remain on your permanent records, including but not limited to academic, employment, and tax records.

Please complete the form and present it with proper photo identification to Human Resources, 412 Sparks Hall, Murray, KY, 42071.

If you are not able to present this form in person with a photo ID, you may mail the completed and notarized form to Human Resources.

Preferred First Name Change Request Form (pdf)

1.8. Visiting Scholar, Military Science Cadre, and Other Guest HR Enrollment Form

Visiting Scholar, Military Science Cadre, and Other Guest HR Enrollment Form

Visiting Scholar, Military Science Cadre, and Other Guest HR Enrollment Form

1.9. Tobacco Free Campus

Murray State University is committed to providing a healthy learning environment for students and a healthy work environment for faculty and staff.  Supervisors who become aware of an employee violating the Tobacco Free Policy should report the violation by completing the Tobacco Free Campus Violation Form and submit the form to Human Resources.  

 

Murray State Tobacco Policy (pdf) 

Tobacco Free Campus Violation Form (pdf)