Forms


Adjunct Instructor Employment Forms

Contact Greg Esplin, HR Coordinator, at 435-652-7503 for any questions.

Department Responsibilities

  1. Adjunct Checklist (pdf) The department administrative assistant completes the form for adjunct member.

New Adjunct Responsibilities

  1. Online Part-Time DSU Application To be complete for all part time positions.
  2. Background Form To be completed for all new and returning adjunct members.
  3. Direct Deposit Form (pdf) Used to set up direct deposit of earnings into employee’s financial institution.
  4. Health Insurance Marketplace Coverage (pdf) As part of the Affordable Care Act, employers are required to provide a notice of the availability of a Health Insurance Marketplace.
  5. Statement of Acknowledgement for Individuals Working with Minors at Dixie State University.
  6. W-4 Tax Withholding Form (pdf) Used to set your tax marital status and allowances for federal withholding tax.
  7. Employment Eligibility Verification form (I-9) Employees complete Section 1 of the I-9 form by clicking on the link below, based on the hiring department. Once this is complete, employees take their forms of ID to the department administrative assistant to complete Section 2 to be hired.

Full Time Staff Member Request to Adjunct Form:


Benefit Forms

Contact Michelle Cabana at 435-652-7523 or cabana@dixie.edu for questions.

Public Employees Health Plan

PEHP Flexible Spending Forms:

Family and Medical Leave Act Forms:

Hartford Life Insurance:

DSU Tuition Waiver Program
For benefited University employees, including those retired, and their spouses and eligible dependents.

Worker’s Compensation Program

  • Workers Compensation Claim form Workers’ Compensation Insurance provides benefits for workers who are injured or suffer an occupational disease as a result of their employment.

The Standard – Long Term Disability:


Faculty Forms

Find Faculty Forms here.
Contact Human Resources at 435-652-7520 for any questions.


Part Time Employment Forms

Contact Jerhett Jerman at 435-652-7522 or jerman@dixie.edu

Hiring Department Responsibility

  1. Part-Time Employment Assignment Form (pdf) Employee’s supervisor completes the form to setup a part-time employee. Used for new part time hires, re-hires, rate increase requests, or new position assignments.
  2. Health Insurance Marketplace Coverage (pdf) As part of the Affordable Care Act, employers are required to provide a notice of the availability of a Health Insurance Marketplace.

New Part Time Employee Responsibilities

  1. Online Part-Time DSU Application To be complete for all part time positions.
  2. DSU Direct Deposit Form (pdf) Use to set up direct deposit of earnings into employee’s financial institution.
  3. Employment Eligibility Verification form (I-9) Employees complete Section 1 of the I-9 form by clicking on the link below, based on the hiring department or employee type. Once this is complete, employees take their forms of ID to the hiring manager to complete Section 2 to be hired.
  4. W-4 Tax Withholding Form (pdf) Use to set your tax marital status and allowances for federal withholding tax.

Payroll Forms

Contact the Payroll Office at 435-652-7611 or payroll@dixie.edu with any questions.

  1. Payroll Deduction

Staff Forms

Contact Human Resources at 435-652-7520 for any questions.

Additional information can be found on the Staff Evaluation page under Employee Resources.


Volunteer Forms

Contact Josh Thayn, Director Event Service & Risk Management at 435-652-7855 for any questions.

Must have Adobe Acrobat Reader® installed on your computer to use the PDF format forms that are on this page. The latest version of Adobe Acrobat Reader® is free at the Adobe web site.