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Miscellaneous Forms/HR Information
Please contact the Human Resource Department for information on and/or the following forms:
  • HealthPartners Health Coverage Change Form
  • HealthPartners Dental Coverage Change Form
  • Miscellaneous Status Change Form (Address/Name change, etc.)
  • Family – Medical Leave of Absence Request Form
  • Certification of Health Care Provider for Employee’s Serious Health Condition (FMLA)
  • Certification of Health Care Provider for Family Member’s Serious Health Condition (FMLA)
  • Physician’s Medical Leave of Absence and Return to Work Recommendation (FMLA)
  • Short Term Disability Employer/Employee Statement (FMLA – Employee)**
  • Short Term Disability Attending Physician’s Statement (FMLA)**
    • **(If employee has opted to purchase Short Term Disability Insurance)
  • Madison National Life Insurance Evidence of Insurability Form (If opting to request consideration for Short Term Disability Coverage after 30 days of employment)
  • Long Term Disability Claim Form
  • Application for Reimbursement of Education Expense (Requires authorization from Department Manager/Supervisor)
  • Harassment & Discrimination Complaint Form (Informal)
  • Harassment & Discrimination "How to File an Employment Discrimination Complaint" (Formal Complaint with State or Federal Agency)

     

     



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    Douglas County Courthouse  |  1313 Belknap Street  |  Superior, Wisconsin 54880  |  Ph: (715) 395-1341