1. Employee Resources Center
2. Forms

Employee Service Center Forms/Links

Click below for up-to-date forms and documents for use in submitting address or name changes, W4 forms for adjusting withholding status when needed, observance of public holidays, requesting time off and more.

Contingent Workforce

• HRSS Query Request Form
• HRSS Transaction Request Form
• SCR Guidance
• Stop Sexual Harassment Fact Sheet
• Stop Sexual Harassment Fact Sheet - Spanish
• Stop Sexual Harassment Notice
• Stop Sexual Harassment Notice - Spanish

Employee

• Applicant Consent Form for CBC Fingerprinting
• Cloud Computing Services
• Request to Employ Retiree Form 2366
• Address Change 1127 Waiver
• Principles of Professional Conduct
• Public Holidays for the Calendar Year
• NY Correction Law - 23 A
• Privacy Act Statement
• Noncriminal Justice Applicant's Privacy Rights
• DOI NYS Tax Release
• Form I-9
• Form I-9 Instructions
• IT Resources Acceptable Use Policy
• Moonlighting (COIB) Waiver Procedures
• O.P. 20-22 Employment of Public Service Retirees
• O.P. 50-1 Corporate Compliance & Ethics Program
• O.P. 20-32 Equal Employment Opportunity (EEO) Program
• O.P. 20-74 Employee Lactation Accomodation
• Personal Criminal History Information Review Sheet
• SCR Guidance
• Stop Sexual Harassment Fact Sheet
• Stop Sexual Harassment Fact Sheet - Spanish
• Stop Sexual Harassment Notice
• Stop Sexual Harassment Notice - Spanish
• Nurse Residency Program Brochure

Employee Discounts

(Valid NYC Health + Hospitals e-mail address may be required to obtain discounts. See individual carrier websites for information)

• Perks at Work
• Working Advantage
• Plum Benefits
• AT&T Wireless Services Discount
• Verizon Wireless Services Discount
• Sprint Wireless Services Discount (Corporate ID: HCLOC_NYC_ZZZ)
• Microsoft Office Professional Plus 2016 Office for MAC 2011 Code 91CD431CBE
• T-Mobile Perks

​​​​Health Benefits

• Health Benefits Application
• Dependent Eligibility Documentation Requirements
• Management Benefits Enrollment Forms
• Vision Care Claim Form
• Healthplex Dental Claim Form
• Health and Fitness Reimbursement Claim Form
• HIP HMO Opt-Out Request Form
• Superimposed Major Medical Claim Form
• Superimposed Major Medical Part D Form
• MBF HIPAA Form
• COBRA Continuation of City Health Plan Coverage
• COBRA Application for continuation of the Superimposed Major Medical Plan (SMMP) and/or Dental and Vision Care Benefit Programs (NOT FOR COBRA CONTINUATION OF CITY HEALTH PLAN COVERAGE)
• Young Adult Dependent Direct Pay Coverage Continuation; (DPCC) Form
• Cobra Rates
• Young Adult Rates - Effective July 2020
• Health Plan Rates
• Lost Check Claim Form
• Video Display Terminals Program entitles eligible employee to vision examinations, lenses and frames, where necessary, biennially. Click here for information on how to access a “VDT Occupational Vision Care Program Benefit Authorization Form.”
• Flexible Spending Account Enrollment/Change Form
• Felxible Spending Account Medical Conversion Form
• Flexible Spending Account Buyout Waiver Form

Labor Relations/EEO

• Reasonable Accommodation Request form
• EEO Complaint Intake Form
• Prohibited Retaliatory Personnel Action by Employers

Leaves of Absence

• Application to Donate Dedicated Sick Leave Under Continuation Program
• Application to Receive Dedicated Sick Leave Under Continuation Program
• Request for Discretionary Sick Leave Form
• Request for FMLA, Child Care Leave and/or Military Leave Form SR-71 (NEW FORM)
• Certification of Health Care Provider for Employee's Serious Health Condition FMLA: Form 2677
• Certification of Employee's Essential Job Function for Employee's Serious Health Condition Form 2677A
• Certification of Health Care Provider for Family Member's Serious Health Condition Family and Medical Leave Act (FMLA) Form 2678
• Certification for Serious Injury or Illness of Covered Service Member/Veteran for Military Family Leave Form 2679
• Certification of Qualifying Exigency For Military Family Leave Family and Medical Leave of Absence ( FMLA) Form 2680

Payroll

• TreasuryDirect Payroll Deductions Enrollment/Changes
• OP 20-70 Direct Deposit

Retirement

• NYCERS - New York City Employees' Retirement System
• Enrollment
• Loan Application – Tier 3, Tier 4, and Tier 6 Basic and Special Plan
• Final Pay Check Lump Sum
• Beneficiary
• Service Retirement Kits
• NYCERS Most Requested Forms

Safety & Wellness

• Workplace Violence Prevention FAQ
• Workplace Violence Incident Form 2829 (Download Paper form here)
• Workplace Violence Incident Form 2829 (Electronic Reporting)

Taxes - Income Withholding

• Certification Of Exemption from Withholding IT 2104-E
• Federal W4 Employee's Withholding Allowance Certificate
• Employee's Withholding Allowance Certificate IT-2104
• NYC Income Tax Form for Non-Resident Employees (NYC-1127)

Timekeeping

• Timekeeping Sheet Change Request
• SR-70

Transit Benefit

• Transit Benefits ESS Page
• Lost/Stolen Check Form
• W-2 Replacement Form

Worker's Compensation

• 1615 Supervisor's Report
• Authorization to Use OHS
• Election of Rate of Charge
• NeedleStick/Body Fluid Exposure Report Form
• Employee's Notice of Injury
• Pink SR70 - Workers Compensation Leave Form
• Supervisor's Workers' Compensation Claim Toolkit