Application & Forms

  Administration

Financial Services Forms

Fund Switch Template
LDPR New-Change Request Form
Payroll JV request form
Budget Load Form
Budget Move Form
Document Invoice Form (DH-11)
Receivable Write-Off Form (DH-101)
E-Deposit Security Request Form (DH-100)
E&E Journal Voucher Request Form
Invoice Routing Form (DH-59)
Monthly Expense Account Report and Coding Sheet (DH-57 and DH-58)
Vendor Input
State of Missouri Tax Exempt Letter

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Fiscal Notes

Staff Review Form FY18
Fiscal Note Worksheet FY18
Overview Questions FY18
Comment Memo FY18
Technical Memo FY18
Statement of No Change FY18
Salaries for Fiscal Notes FY18
Training Packet FY18

Fixed Assets

Non-Expendable Property Transfer/Reassignment (DH-60)
Non-Expendable Property Removal Request (DH-85)
Fixed Asset/Property Tab Substitution/Waiver Request (DH-88)
Request for Listing of DHSS Fixed Assets/Telecommuter Equipment (DH-87)
Listing of Loaned Equipment (DH-86)
Fixed Asset/Property Tag Assignment
Report of State Owned Surplus Property (SS1)
Redistribution Authorization (SS-2)

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Purchasing and Contracting Forms

Contract Language and Attachments with OMB Updates MAIN
Standard Contract Language with OMB updates
Attachment A - Certifications with OMB updates
Attachment B - Subrecipient Conditions with OMB updates
Attachment C - Subrecipient Annual Financial Report (MO580-3091)
Business Entity Certification, Enrollment Documentation, and Affidavit of Work Authorization Attachment
Business Associate Provisions Attachment
Terms and Conditions
Forms & Templates
DH-10 Purchasing Request
DH-40 Contract Monitoring Site Visit Report
Invitation for Bid Shell Document
MO 580-3094 Invoicing Tool for Calculating Indirect
Participation Agreements
DH-74A Participation Agreement for Professional and Special Services Provider
DH-74A Terms and Conditions
DH-74H Missouri Women, Infants and Children Program - WIC Retailer Agreement
DH-96 Summer Foods Service Program Inspections Participation Agreement
DH-96 Summer Foods Service Program Inspections Participation Agreement E-Verify
DH-97 TB Participation Agreement
DH-98 Environmental Child Care Sanitation Inspections Participation Agreement
E3.70 Onsite Wastewater Treatment System Construction Review
580-3166 STEMI Agreement
580-3167 Stroke Agreement
580-3200 Trauma Agreement

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  Communicable

Vaccine-Preventable Investigation

Poliomyelitis Report
Rash Investigation
Tetanus Report
Mumps Report
Pertussis Report
Record of Investigation of Diphtheria

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  Human Resources

Benefits/Payroll

New Hire Benefits Packet
New Hire Paperwork (9/21/17)
H and I New Hire Paperwork (9/21/17)
I-9 Form (fillable) New
I-9 Form (paper) New
I-9 Instructions New

Payroll & Employee Reimbursement Direct Deposit Application
Form W-4 Missouri
Form W-4 Federal
Local City Taxes

Employee Benefits Info Sheet

Business Travel Card
Cafeteria Change Form

Overtime Advisement and Acknowledgement

Classification

Check List to Establish New Positions or Initiate a Review of Position
Employee's Guide to Position Description Forms
Position Description Form
Position Description Form for Broadbanded Manager Positions

Complaint Forms

Labor Agreement Grievance Review Request (5-11)
Grievance Review Request PF-17 (8-06)
Internal Complaint (12-15-2011)

Employee/Employment-Employee/Employment Changes

Human Resources Functional Chart New
Application for DHSS Employment
Application for Transfer/Reemployment
Outside Employment (PF-56) (2-13)
Request For Change in Work Schedule

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Employee Performance Planning and Appraisal System

Employee Performance Log (MOPD #145) (.pdf) -- (.doc)
Employee Work Plan

PERforM - Helpful Hints
PERforM - Basic Instructions
PERforM - Condensed
Needs Improvement Ratings
PERforM Portal - FAQs
PERforM Appraisal Document - SUPERVISORY STAFF
PERforM Appraisal Document - NON-SUPERVISORY STAFF
PERforM Planning Document Non-Supervisory (with Standard Objectives)
PERforM Planning Supervisory (with Standard Objectives)
PERforM Performance Appraisal Response Request Form
Determining the Need for an Annual PERforM Rating

Process for Employee PERforM Response Request

Filling Positions

Request to Establish (RTE)
Job Announcement Blurb Checklist
Salary Justification NEW
Confirmation of Acceptance
Request to Fill

Experiential Learning Program NEW

Experiential Learning Program Defined (assistance for staff)
Experiential Learning Interest Form (for student seeking experience)

Internship Forms

Internship Request Form (for program to request approval)
Intern Information Sheet
Application for Record Review
Internship Packet - Statements and Policies
Time Tracker Tool

Mentorship/Shadowing Forms

Application for Record Review          
Mentee/Shadowing Packet - Statements and Policies

Interview Forms

Hiring Process
Employee Benefits
Hiring Recommendation Sheet
Interview Questions and Rating Sheet NEW
Criminal History Disclosure Form NEW
Employment Interview Plan
Selection Interviewer Signature Sheet
Structured Employment Interview Method NEW

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Miscellaneous

Service Awards - Gift Catalog
Years of Service Plaque Descriptions

Application for Record Review
Assessment for Special Request Training
Confidentiality Statement
Desk Manual Process Template
DHSS Workers’ Compensation Reporting Packet NEW
Documentation Review Tool
Employee of the Month Nomination Form
Health Care Certification (FMLA) PF-46 (Admin. Policy 8.12A)
Health Care Certification for Family Member's Serious Health Condition PF-46 (Admin. Policy 8.12B)
Health Care Certification for Military Covered Servicemember Leave PF-46 (Admin. Policy 8.12C)
Incident Report (PF-55)
Statement of No Conflict of Interest (11.11A)
Web Site Access Request

Pay Grids and Classes

Pay Ranges for Broadbanded Managers Updated
UPC Pay Grid A (effective July 1, 2016)
UPC Pay Grid B (effective July 1, 2016)

Pay Grids and Classes
DHSS Class Titles

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  Emergency Planning

Bio-Chemical Terrorism

Bioterrorism Surveillance (BTS Form 1) and Instructions
BTS Form 1 Cheat Sheet

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  Environmental

Food Safety

580-2659 Food Product Complaint Record
580-3058 Application for Food Establishments

Onsite Sewage

Construction Permit Application Review Sheet
Construction Permit/Final Inspection
Notice (OWTS Construction Stop Order) (.pdf) -- (.doc)
OWTS Professional Complaint Record
Violation Notice

Environmental Childcare

DC-38 Reimbursement Request For Child Care Sanitation Inspections (07/2010)
DC-38 Instructions
DC-39 Late Inspection Reimbursement Request

Environmental Health Services

Change Order
Recall Follow-up Report Form
Recall Follow-up Summary Report Form
Complaint Investigation Record

 

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  Grant Application Forms

Assurance Forms
Certification Forms
DH42 Administrative Action Report Form
Fringe Rate Estimates FY2018
Fringe Rate Estimates FY2017
Fringe Rate Estimates FY2015
Fringe Rate Estimates FY2014
Fringe Rate Estimates FY2013
Fringe Rate Estimates FY2012
Indirect Cost Rate Agreement FY18
Indirect Cost Rate Agreement FY17
Indirect Cost Rate Agreement FY16
Indirect Cost Rate Agreement FY15
Indirect Cost Rate Agreement FY14
Indirect Cost Rate Agreement FY13
Indirect Cost Rate Agreement FY12
Network and Application Support Description - FY17
Network Access and General Application Support – effective July 1, 2017
Network Description - prior to July 1, 2017
Notification of Proposal Development
Request for Carryover of Grant Funds
Request for No-Cost Extension
OMB Checklist
Set Up of Grants Prior to Receipt of Official Notice of Grant Award
SF-424 Application
SF-424A Application Budget

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  ITSD Forms

Automated Security Access Processing (A.S.A.P.)
ITSD Project Form (Customer Service Request)
Portable Laptop Agreement
Surplus DH-60 (see ITSD Policy 22.3 A – Procedure to Surplus Equipment)
Web Server Project Memorandum of Understanding (.doc) -- (.pdf)

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  Letterhead/Fax Cover Sheet/Memo

Central, District and Area Office Forms

DHSS Letterhead
DHSS Fax Cover
DHSS Memo

Bureau of Home and Community Based Services Regional Office Forms

Letterhead
Region 1
Region 1- Regional Evaluation Team
Region 2
Region 2- Regional Evaluation Team
Region 3
Region 3- Regional Evaluation Team
Region 4
Region 4- Regional Evaluation Team
Region 5
Region 5- Regional Evaluation Team

Long Term Care Regional Office Forms

Letterhead
Region 1
Region 2
Region 3
Region 4
Region 5
Region 6
Region 7

Fax Cover
Region 1
Region 2
Region 3
Region 4
Region 5
Region 6
Region 7

Letterhead
Eastern District
Northeastern District
Northwestern District
Southeastern District
Southwestern District
Cameron Area Office
Cape Girardeau Office
Columbia Area Office
Joplin Area Office

Fax Cover
Eastern District
Northeastern District
Northwestern District
Southeastern District
Southwestern District
Cameron Area Office
Cape Girardeau Office
Columbia Area Office
Joplin Area Office

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  Local Public Health Agency

DH-37 Local Public Health Agency - Annual Financial Report

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  Vendors

DH-38 Vendor Request for Payment

  General Services/Warehouse

Cisco Phones and Vacant Positions Guidance
Forms - Available from the DHSS Warehouse
Move Request DH-90
New Employee - New Phone Request
Non-Expendable Property Transfer/Reassignment DH-60
Printing Requisition Form - Form MO 300-0298E
Request for Forms DH-48 (.pdf) - - (.doc)
Vehicle Expense Form DH-84
Wireless Service Requests
Work Order DH-61

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