Thomas Jefferson University

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Forms & Documents Center

Our goal is to provide Human Resources forms electronically to reduce print costs and make the forms easily accessible to the Jefferson Community. If you don't see the form you need listed here, contact the Human Resources Department and they will send you the form you need.

Some of the form formats provided here requires Adobe Acrobat Reader or Microsoft Word. See the link below to acquire the plug-ins for your browser. This plug-in will allow you to view the PDF forms within your Internet Browser.

Instructions for Saving Forms:

If you encounter trouble saving a form, right click the form link and choose "Save Target As" or "Save Link As". This will allow you to save the file locally on your computer for editing/printing.

Adoption Assistance

Benefits Information

Business Travel Accident Insurance

Continuing Education/Training

Dental Insurance

Delta Dental Claim Form
Delta Dental SPD
Aetna Dental SPD (SPD coming soon)

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Employee Assistance

Employee Discipline

Employee Handbook

Employee Orientation

Employment

Probation
Surviving Change
Sexual Harassment
Jeff Temp Request Form for JUP
Jeff Temp Request Form
FLSA Overtime Presentation
TJU/JUP PAR Justification Form
PAR — for Departments requiring PARs, please contact Jeff Graphics at
     http://www.jeffgraphics.com or (215) 503-7450 to place an order.

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Employment Verification

Flexible Spending Account (FSA)

Health Insurance

Personal Choice Out-of-Network Claim Form
Personal Choice PPO (SPD coming soon)
Keystone Out-of-Network Claim Form 
Independence Blue Cross Consumer Driven Health Plan (CDHP) (SPD coming soon)
Prescription Insurance - Optum Rx Member Reimbursement Form

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Non-FMLA Leave of Absence

Performance Management

Retirement/Pension Plans

TIAA-CREF Individual Counseling Session Schedule

Defined Contribution Plans
Thomas Jefferson University Defined Contribution Retirement Plan Summary Plan Description

Thomas Jefferson University Hospitals, Inc. Defined Contribution Pension Plan Summary Plan Description
Thomas Jefferson University Hospitals, Inc. Defined Contribution Pension Plan Summary Annual Report
Thomas Jefferson University Hospitals, Inc. Defined Contribution Pension Plan Form 5500

Jefferson University Physicians Retirement Plan Summary Plan Description
Jefferson University Physicians Retirement Plan Summary Annual Report
Jefferson University Physicians Retirement Plan Form 5500

Thomas Jefferson University Voluntary 403b Tax Deferred Annuity Plan Summary Plan Description
Thomas Jefferson University Voluntary 403b Tax Deferred Annuity Plan Summary Annual Report
Thomas Jefferson University Voluntary 403b Tax Deferred Annuity Plan Form 5500

Thomas Jefferson University Hospitals, Inc. Voluntary 403b Tax Deferred Annuity Plan Summary Plan Description
Thomas Jefferson University Hospitals, Inc. Voluntary 403b Tax Deferred Annuity Plan Summary Annual Report
Thomas Jefferson University Hospitals, Inc. Voluntary 403b Tax Deferred Annuity Plan Form 5500

Jefferson University Physicians Voluntary 403b Tax Deferred Annuity Plan Summary Plan Description
Jefferson University Physicians Voluntary 403b Tax Deferred Annuity Plan Summary Annual Report
Jefferson University Physicians Voluntary 403b Tax Deferred Annuity Plan Form 5500

Thomas Jefferson University Retirement Plan for Faculty and Sr. Administrative Staff
Summary Plan Description

Thomas Jefferson University Retirement Plan for Faculty and Sr. Administrative Staff
Summary Annual Report

Thomas Jefferson University Retirement Plan for Faculty and Sr. Administrative Staff Form 5500

Thomas Jefferson University Hospitals, Inc. Retirement Plan For Sr. Administrative Staff Summary Plan Description
Thomas Jefferson University Hospitals, Inc. Retirement Plan for Sr. Administrator Staff Summary Annual Report
Thomas Jefferson University Hospitals, Inc. Retirement Plan Sr. Administrative Staff Form 5500

Defined Benefit Plans
Thomas Jefferson University Employees' Pension Plan Summary Plan Description
Thomas Jefferson University Employees' Pension Plan Annual Funding Notice
Thomas Jefferson University Employee's Pension Plan Form 5500
Thomas Jefferson University Employee's Pension Plan Master Trust Form 5500

Thomas Jefferson University Hospitals, Inc. Employees’ Pension Plan Summary Plan Description
Thomas Jefferson University Hospitals, Inc. Employees’ Pension Plan Annual Funding Notice
Thomas Jefferson University Hospitals, Inc. Employees’ Pension Plan Form 5500
Thomas Jefferson University Hospitals, Inc. Employees’ Pension Plan Master Trust Form 5500

Additional Information
Retiree Checklist

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Short Term Disability Insurance

Tuition Assistance

Transportation

Vision Insurance

Workforce Management