DPH Employee Toolkit -- DPH Forms

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Administration - Updated 03/10/10

Form	Format, Size (if DPH file)	Last Modified* (if DPH file)	Notes
Authorization of Fees for Expert Speaker (Travel Forms Workbook)	XLS, 560 KB	12/18/09; Replaced 03/10/10	Addendum to "Conference Authorization Form" - Authorization of Fees for Expert Speaker. Download 2010 workbook containing forms for travel reimbursement and tab to the form you need.
Conference Authorization Form (Travel Forms Workbook)	XLS, 560 KB	12/18/09; Replaced 03/10/10	Conference authorization form for workshops, seminars, training courses, etc. Download 2010 workbook containing forms for travel reimbursement and tab to the form you need.
DPH Six Forks Campus ID/Card Building Access Badge Request	PDF, 22 KB	02/07/06	Badge request form for DPH Employees on Six Forks Campus.
DPH Access Badge/Card Request (Downtown)	DOC	N/A	Badge request form for DPH Employees located in downtown Raleigh facilities; NOT for Dix Campus (Royster).
DPH Dix Campus Identification (ID) Badge/Swipe Card Request Form	DOC, 97 KB	N/A	DPH Employees located on Dix Campus (Royster); DIRM form.

Budget

Form	Format, Size (if DPH file)	Last Modified* (if DPH file)	Notes
Cost Allocation Plan (CAP) Update Request	DOC, 41 KB	02/08; Last Upload 09/21/09	Form used by the Cost Accounting Branch in establishing and maintaining the Cost Accounting Plan; documents the initiation of cost centers (RCCs) as well as changes to existing centers.
Cost Allocation Plan (CAP) Update Request Instructions	DOC, 26 KB	02/08	Instructions for completing the Cost Allocation Plan (CAP) Update Request.
Fixed Asset Input Form (FAS-1)	HTML	N/A	DHHS Form for inventorying fixed assets.
Fixed Asset Input Form Instructions	PDF	N/A	Instructions to DHHS form for inventorying fixed assets.
Review Meeting Summary	DOC, 33 KB	07/31/09; Last Upload 09/28/09

Contracts

Form	Format, Size (if DPH file)	Last Modified* (if DPH file)	Notes
Contracts Forms	Various	See Contracts Forms page	Contracts Unit web site with full list of forms, primarily in Word format.

Grants Management

Form	Format, Size (if DPH file)	Last Modified* (if DPH file)	Notes
Form 606A: Notification of Application for Grant Funds/Awards	PDF	N/A	State agencies are required by statute (G.S. 143C-7-1) to notify the Office of State Budget and Management (OSBM) of all applications made for grant funds and/or other funds that require an application.
606A Instructions: Instructions for Reporting Grant Applications/Awards	PDF	N/A	Line-by-line instructions for Form 606A
SF 424: Application for Federal Assistance	DOC	N/A
SF 424 Example and Instructions	DOC, 390 KB	08/26/08	SF 424 example provided by DPH
SF 424A: Budget Information - Non-Construction Programs	PDF	N/A
SF 424A Example and Instructions	DOC, 390 KB	01/22/09	SF 424A example provided by DPH
Cost Allocation Plan (CAP) Update Request	DOC, 41 KB	02/08; Last Upload 09/21/09	Form used by the Cost Accounting Branch in establishing and maintaining the Cost Accounting Plan; documents the initiation of cost centers (RCCs) as well as changes to existing centers.

Health and Safety

Form	Format, Size (if DPH file)	Last Modified* (if DPH file)	Notes
Hazardous Substance Inventory List	Excel, 60 KB	05/05/08	Worksheet for hazardous substances inventory listing.
Supervisor's Accident/Incident Investigation Report	PDF	N/A	Supervisor's accident investigation report form from OSP's web site.

Human Resources

DHHS HR Forms

Form	Format, Size (if DPH file)	Last Modified* (if DPH file)	Notes
DHHS Human Resources Forms	Various	N/A	Various HR files and formats - One stop for DHHS HR forms.

DPH HR Forms

Form	Format, Size (if DPH file)	Last Modified* (if DPH file)	Notes
Beacon Training Acknowledgement	DOC, 54 KB	06/2008	This training MUST be completed before or on the first day of employment.
Employee Action Request	DOC, 142 KB	06/2008	N/A
Position Action Request	DOC, 139 KB	06/2008	N/A

Purchasing

Form	Format, Size (if DPH file)	Last Modified* (if DPH file)	Notes
Correction Enterprises Print Order Form (DC 258)	PDF	N/A	Complete for publication print orders.
Fixed Asset Input Form (FAS-1)	HTML	N/A	DHHS Form for inventorying fixed assets.
Fixed Asset Input Form Instructions	PDF	N/A	Instructions to DHHS form for inventorying fixed assets.
N.C. DHHS Publication Review (PA-2)	PDF	N/A	Form to initiate final signoff for all printed and Web materials created within DHHS. Call 733-9190 to talk with your Public Information Officer.
Request for Purchase Exception	XLS, 25 KB	09/15/09	Subject to the OSBM July 24, 2009 Budget Management Restrictions Memorandum for Fiscal Year 2009-2010.
Telecommunications Cable Service Request (TO-4)	DOC	N/A	Request cable services from ITS.
Telephone Order Service Request (TO-5)	DOC	N/A	Request telephone services from ITS.
Procedures for Spending Funds	PDF, 37 KB	10/02/09	Chart for procedures and applicable forms.
DPH Purchase Request Form	XLS, 43 KB	10/05/09; Replaced 10/07/09	DPH Purchase Request form used for ordering supplies, materials, and other equipment. When downloading, a box may appear with an “ok” button near bottom of box; click the button to utilize form.
DPH Purchase Request Form Instructions	PDF, 39 KB	10/02/09	Instructions for using the DPH Purchase Request Form (see above).

Records Management

Form	Format, Size (if DPH file)	Last Modified* (if DPH file)	Notes
Public Records Series Listing	DOC or PDF	N/A	Complete if a schedule needs to be developed and if a schedule needs to be updated.
Records Retrieval Form	PDF	N/A	Use to request records stored at the State Records Center or other storage facilities.
Request for Disposal of Unscheduled Records	PDF, 145 KB	N/A	Approval must be obtained to destroy records not listed on a schedule.

Risk Management

Form	Format, Size (if DPH file)	Last Modified* (if DPH file)	Notes
Conflict of Interest	PDF, File available on external web site	N/A	N/A
Federal False Claims Act Education Employee Notice	DOC, 32 KB	04/08; Last Upload 9/28/09	N/A

Travel - Updated 03/10/10

Form	Format, Size (if DPH file)	Last Modified* (if DPH file)	Notes
Accident Reporting Form/Vehicle Accident Report	PDF	N/A	Motor Fleet Management's vehicle accident reporting form.
Budget/Travel Authorization Form (BDA)	DOC, 24 KB	05/07	DHHS travel authorization form.
DOT Gasoline Facilities/Automated Fuel Sites	HTML	N/A	JPG map of automated fuel sites in NC.
Employee Travel Advance Request Form	Excel, 25 KB	07/08	Submit at least 5 days before travel.
Itemized Statement of Charges for Travel (Form 25T)	PDF	N/A; Link Updated 10/16/09	Industrial Commission's mileage reimbursement form related to workers' compensation.
Payment Verification Form	DOC	N/A	Direct deposit of travel reimbursement (NOT monthly payroll).
Request for Travel Exception	XLS, 18 KB	09/15/09	Subject to the OSBM July 24, 2009 Budget Management Restrictions Memorandum for Fiscal Year 2009-2010.
State Property Incident Report	DOC	N/A	For use by state department head to report to the Director of the State Bureau of Investigation information or evidence of an attempted arson, arson, damage to, theft from, or theft of, or embezzlement from, or misuse of any State owned personal property, buildings or other real property.
2010 Travel Forms Workbook Effective January 1, 2010 Conference Authorization Form Conference Authorization Additional Speaker Attachment Authorization of Fees for Expert Speaker Reimbursement of Travel and Expenses Incurred in the Discharge of Official Duty Non-State Employee Reimbursement of Travel and Other Expenses Subsistence Rates	XLS, 560 KB	12/18/09	Workbooks containing forms for travel reimbursement. Download workbooks and tab to the form you need.
Procedures for Spending Funds	PDF, 37 KB	10/02/09	Chart for procedures and applicable forms.

*Note: "Last Modified" dates apply only to documents maintained by the Division of Public Health and not linked on an external web site.

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