Department of Public Safety Forms 

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Request for State of North Carolina Awards


Human Resources

                      HR Staff Directory
HR 001        Request to Post
HR 002        Report Request (Use Explorer)
HR 003        DPS Interview Checklist
                     DPS Interview Procedures

HR 004        Criminal History Record Check      
HR 005        Applicant Verification

HR 006        Interview Rating (Long version)
                    Interview Rating (Addendum - Long version)             

                    Interview Rating (Short version)
                    Interview Rating (Addendum – Short version)

HR 007        Interview Summary
HR 008        Professional Reference Check
HR 009        Request for Candidate Pre-Approval
HR 012        Applicant Checklist of Employment Requirements
HR 013        DPS Employment Statements
HR 014        BEACON Data
HR 015        Prior Service
HR 016        Degree Verification Request
HR 017        Personnel Action Request
HR 018        Conditional Offer Of Employment
                       Instructions for Completing the Form I-9
                       I-9 Employment Eligibility Verification
HR 019         Final Offer Letter
HR 020        Request for Secondary Employment                       
                    Mandatory Direct Deposit Notification
                    Direct Deposit Enrollment and Change Form

HR 021        DPS Personal Data Change
HR 022        Request for Supplemental Staff
                       Supplemental Staff Checklist

HR 401        Steps for Requesting Classification Reviews
HR 402        Organizational Management Action request (OMAR)
HR 403         ADA Checklist
HR 404         Essential Job Functions (EJFs)
HR 405         Essential Job Functions Summary

HR 407        OSHR Qualification Worksheet (NEW)

HR 408         In-Range Salary Adjustment Request (IRSA) Form- Job Change
HR 409         In-Range Salary Adjustment Request (IRSA) Form- Labor Market
HR 410         In-Range Salary Adjustment Request (IRSA) Form- Equity
                       OSP Equity Analysis Tool (2014)
                       OSP Equity Guidelines 
                       OSP Position Description Form, HR 403 ADA Checklist and a link in bundle to HR 404 DPS Essential Job Functions   
                       Career-Banding Rate 
                       Salary Schedule   
                       Medical Schedule   
                       Competency Assessment 
                       Performance Rating Maintainer List  
                       Instructions for Performance Review Reports Instructions for Entering Performance Ratings in BEACON SAP



Regional Employment Offices (REOs)

Forms and Checklists: Effective May 2019
BCOT Information for Applicants
Conditional Offer of Employment (CO Full Class)
Conditional Offer of Employment (Trainee CO 0-11 Months)
Conditional Offer of Employment (Trainee CO 12-23 Months)
Employment Application Addendum 
Employment Statements (CO)


Prisons Pre-Employment Packages - Effective May  2019

Eastern Carolina Regional Employment Office (ECREO) 
Piedmont Triad Regional Employment Office (PTREO)
Raleigh Regional Employment Office (RREO)
Western Foothills Regional Employment Office (WFREO) 

Juvenile Justice Pre-Employment Packages - Updated Oct. 2018
Eastern Carolina Regional Employment Office (ECREO) 
Piedmont Triad Regional Employment Office (PTREO)
Raleigh Regional Employment Office (RREO)
Western Foothills Regional Employment Office (WFREO) 

HR 549          Workplace Violence Incident Rerport
HR 549a        Workplace Violence Victim/Witness Account Form

HR 554/554a Informal Discussion Worksheet/Outcome of Informal Discussion (Opens only in Internet Explorer)

HR 555          Step 1 Grievance Filing
HR 556          Step 2 Grievance Filing
HR 556(a)     Step 2 Employee/Witness Form

HR 560     NCVIP Performance Appraisal Summary Rating Form
                  HR560 Policy
HR 562    DPS Documented Counseling Session/Employee Action Plan  (Opens only in Internet Explorer)

HR 604         Employee Separation Checklist

New Employees

Create an NCID

Time and Leave

Time Sheet Form (Monday start)  
Time Sheet Form (Sunday start)  
Time Sheet Form (temporary employees)

WH 380 E Certification of Health Care Provider for Employee's Serious Health Condition Form (FMLA)
WH 380 F Certification of Health Care Provider for Family Member's Serious Health Condition Form (FMLA) 


Americans with Disabilities Act (ADA)

ADA Forms:

HR 800 Request for Reasonable Accommodation
HR 801 Request for Reaonable Accommodation – CJ Training
HR802 ADA Coordinator's Log
HR 803 ADA Coordinator's Checklist
HR 804 ADA Title (1) Disability Law

ADA Letters:  (Please do not change the overall content of the below ADA letters).

Acknowledgement Letter
Initial Letter to Healthcare Provider
First Follow-Up Letter to Healthcare Provider
Follow-Up Letter to the Employee
Second Follow-Up Letter to Healthcare Provider
Additional Medical Information Letter to healthcare Provider
Request for Updated State Application (This template is used by the ADA Compliance Officer ONLY)

In-Service (Annual Re-Certifications) Essential Job Functions:

HR 805 In-Service Essential Job Functions - CPR
HR 806 In-Service Essential Job Functions – Batons, Restraints, CRDT
HR 807 In-Service Essential Job Functions – Firearms (Prisons)
HR 808 In-Service Essential Job Functions – Firearms (Community Corrections)


Family Medical Leave

Family Medical Leave  

Family Illness Leave

Benefits, Safety & Health

Workers' Compensation Employee Handbook    Updated Nov. 2018!

Workers' Compensation Supervisor Handbook    Updated Nov. 2018!

Corvel, Worker's Compensation Authorization/ Physicians' Report/Pharmacy Guide   
NCIC18   Notice of Accident to Employer
NCIC 19   Report of  Employee Injury or Occupational Disease   

HR 205 Workers Comp Leave Request Form
HR 206 Workers Comp Leave Request Instructions
HR 207 
Workers' Compensation Return to Work Request/Plan

Request for Reasonable Accommodation form
Leave of Absence Request Form
HR 104 Short-term Disability Application and Instructions Updated August 2017!
HR 105 Disability Application - Required Form  

HR 107 VSL Application/Medical Certification Updated May 2018!
HR 108 VSL Donation Form & Guide
HR 109 VSL Worksheet

HR 201 Workers Comp - Employee Initial Report of Injury Updated August 2017!
HR 203 Workers Comp – Accident/Incident Investigation Report Updated August 2017!



Excel Inventory – Basic Report 6-30-2019 
Excel Inventory – Expanded Report 6-30-2019
Excel Worksheet Inventory Instructions 6-30-2019
Inventory Memo (Adult Correction) - 6-30-2019 

OSC Vendor 47PI   Vendor Electronic Payment Form - GEMS
CNTR 001      2019 Travel Authorization (effective 7/1/2019) Excel
CNTR 001a   Training Authorization for Division of Administration and Division of Adult Correction and Juvenile Justice
CNTR 002     Employee Advance Request

CNTR 003   2019 Travel Reimbursement (effective 7/1/2019) - Excel - This form may be used, or you can use your section approved form. Individual sections have entry-friendly versions tailored to their budget codes that will remain viable as long as they are portrait-oriented, contain the same information, and include instructions, certifications, DPS logo, Department name, Division/Section name, and a form revision date.] Version for Boards and  Commissions with $.25 rate: CNTR 003  Boards and Commissions Travel Reimbursement Form. 
CNTR 004    Direct Deposit Reimbursement

CNTR 005     Direct Processing Form
CNTR 006A  Contractor Personal Services Contract Questionnaire
CNTR 006B  DPS Personal Services Contract Questionnaire
CNTR 007     Independent Contractor Time Report (Opens only in Internet Explorer)
CNTR 008 – Fixed Asset Action Request Worksheet
CNTR 009 – Donation Acceptance Form
CNTR 013 – Missing/Stolen Asset Form
CNTR 011     Request to Lower Wall in BEACON (Opens only in Internet Explorer)
CNTR 012     Moving Quote (Opens only in Internet Explorer)
CNTR 014     E-billing Security Access Form (Opens only in Internet Explorer)
CNTR 015     NCAS Security Form  NCAS Security Form Instructions             
CNTR 016   Accounting Reclassification Request (Opens only in Internet Explorer)


(W-4)    Internal Revenue Service Employee's Withholding Allowance Certificate
(NC-4)   N.C. Department of Revenue Employeee's Withholding Allowance Certificate
(NC-4 EZ)  N. C. Department of Revenue Employee's Withholding Allowance Certificate

Information Technology

Non Disclosure Agreement

Office of Staff Development

OSDT 001  Training Course Record (Opens only in Internet Explorer)

Law Enforcement

Return to Duty Power Point
Return to Work Request/Plan

HR 201  Workers Comp - Employee Initial Report of Injury Updated August 2017!
HR 203  Workers Comp – Accident/Incident Investigation Report Updated August 2017!
HR-205  Workers' Compensation Leave Request Form
HR-206  Workers' Compensation Leave Instructions

Corvel Workers' Compensation Authorization/Physician's Report/Pharmacy Guide 
Workers' Compensation Process Power Point

Law Enforcement Blood Exposer Forms

Antibody Testing Consent and Consent to Release Medical Information (DPS-180)
Motion to Investigate Exposure (DPS-181)
Order to Investigate Exposure (DPS-182)
Order to Test Blood (DPS-183)
Employee Antibody Testing Consent and Authorization to Release Medical Information (DPS-184)
Body Fluid Exposure Form (DPS-187)

« this page last modified 07/16/19 »