1. Benefits
1.1. HIPAA Privacy Notice


Health Insurance Portability and Accountability Act

HIPAA Privacy Notice 


1.2. 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)





1.3. Salary Reduction Agreement Form

Salary Reduction Agreement Form (PDF)

1.4. 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)

 

1.5. Tuition Waivers

Murray State Tuition Waivers

 


MSU Tuition Waiver Form (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. 

Deadline information can be found on the Academic Calendar link: here.  



Non-Murray State Employee 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. 

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








1.6. 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. The injury must be reported to Human Resources within 24 hours.

Quick Guide 


1) The department will need to give the injured employee the Kentucky Brickstreet Injury Kit Packet and have the required forms completed, which are:
   • Medical Waiver and Consent Form(Scan or fax to 3464 HR with employee/student worker signature)
   • Physician Statement of Physical Capabilities (The healthcare provider is required to complete this form at the initial appointment and the employee must return it to Human Resources)
   • Notice of Designated Physician(Scan or fax to 3464 HR with employee/student worker signature)

2) The department will need to complete the First Report of Injury or Illness with all of the pertinent information immediately, but no later than 24 hours after the injury is reported. All questions relating to the accident must have detailed answers. (email sleach@murraystate.edu the form without social security number within 24 hours).

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. 

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.