Business and Service Forms



Access Control Executive Designation Form

Access Request

Accommodation Under the Americans with Disabilities Act, Employee Request for

Accommodation Under the Americans with Disabilities Act, Student/Resident Request for

Accounting of Disclosures of Protected Health Information

Acknowledgement of Receipt of Notice of Privacy Practices | (Spanish version)

Agreement - Clinical Study (Template)

Agreement - Sponsored Research (Template)

Alcoholic Beverages on Campus (faculty/staff only), Request for

Alcoholic Beverages on Campus for Student Organizations, Request for

Amendment Denial Letter

Answer Sheet Request Form

Applicant Log for the Position Of:

Approval and Payment to Employee for Additional Services, Request for

Audiovisual/Classroom Support Request Form

Authorization of Signature, Request for


Benefits Forms

Billing for Studies Involving Human Subjects

Biographical Data Sheet

Blackboard New Course Request Form (Continuing Education) (rtf)

Blackboard New Course Request Form (Non-official) (rtf)

Blackboard New Course Request Form (Continuing Education) (rtf)

Blackboard-User Access Form (xls)

Blackboard Course Deletion Form (rtf)

Bookstore Departmental Requisition

Bookstore Textbook and Manual Request Form

Business Card Request Form

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Cash Receipt Deposit Voucher

Certificate of Proposal

Change of Chairman or Head

Chemical Waste Pickup Request

Clinical/Adjunct Faculty Appointment Letter

Clinical Trial Study Information to UT Medicine

Communications Service Request Form

Confidentiality/Security Acknowledgement

Conflicts of Interest Reporting Form

Consent and Agreement for Treatment

Consortium Agreement Template - HSC As Prime Awardee

Consortium Agreement Template - HSC As Subawardee

Contractors and Vendors ID Request Form

Course Evaluation Request Form

Credit Card Merchant Request

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Data Use Agreement

Debarment Certification

Departmental Postage Request

Departure for International Visitors, Confirmation of

Deposit Request-Office of Sponsored Programs

Direct Deposit Authorization Form

Dispose of State Records, Request for Authority to

Dual Positions of Honor, Trust or Profit, Request for Approval of

Electronic Funds Transfer Form

Electronic Storage Device Disposal Request

Eligibility to Handle Select Biological Agents or Toxins, Annual Statement of

E-mail Authorization Agreement

Emergency Requisition Justification

Employee/Independent Contractor Classification Checklist

Employee Separation Form (UT System)

Employer's First Report of Injury or Illness

Exam Scoring Request Form

Exit/Clearance Form

Extension of Stay, Request for

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Fabricated Property, Record of

Facilities Management Request Work Online

Faculty CA-1: Request for Clinical or Adjunct Faculty Appointment

Faculty CI-1: Supplement to Faculty Appointment Packets

Faculty CJ-1: Request for Cross or Joint Appointment

Faculty CJ-1: Supplement to Joint Appointment Packets

Faculty FA-1: Request for Faculty Appointment of Associate Professor or Professor

Faculty FA-2: Request for Initial Faculty Appointment

Faculty FA-3: Request for Initial HSC and VA Appointment

Faculty FA-4: Request for Faculty Promotion from Instructor

Faculty PA-1: Request for Promotion in Rank

Faculty Recruitment Report

Fitness for Duty Certification

FMLA: Certification of Physician

FMLA: Department Notification to Employee

FMLA: Request for Time Off

Fellowship (Stipend) Award Authorization

Flex Time, Request for

General Stores Requisition

Gift Log

Grants, NIH Modular Budget for HSC Internal Use

HIPAA Patient Privacy Forms

Hotel Occupancy Tax Exemption Form

Human Subjects Letter to NIH

Hybridoma Facility Service Request Form

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ID Card Request Form

Information Management and Services Service Request Form

Instrumentation Services Service Request Form

Inter-Department Transfer Voucher

International Visitor Data


I-9 Employment Eligibility Verification

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J Certificate of Eligibility Application Form

J-2 EAD, Apply for/Renew

Key Request

Lease of Building Space Informational Questionnaire

Letter for Misdirected Fax

Library Borrower Registration Form

Library Document Delivery Services (ILLiad)

Library Loansome Doc Delivery (HSC affiliates)

Library/Ovid Online Registration Form

Library Purchase Request Form

Library Reserve Material Form

Linen Service, Authorization for

Linen Service Requisition

Local/State Voucher

Lodging Rate, Request to Increase

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Management Oversight Questionnaire

Materials Management Shipping Request

Materials Management Storage Request

Memorandum of Understanding for Faculty with VA-UTHSCSA Joint Appointments

Monthly Time Report

Multimedia Production Services Service Request Form

Name Change Form - Former Employees

New Mail Stop Code Request Form

Notification of Faculty Vacancy

Notification of an On-the-Job Injury

Notification of Intent to Hire Academic Candidate

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Patient Authorization for Release of Health Records | (Spanish version)

Patient Privacy Forms (HIPAA)

Payment by Electronic Funds Transfer

Payor Distribution Form

Peptide Request Form

Performance Review for Classified and A&P Employees

Performance Review for New Employees (Probationary)

Petty Cash Fund Request

Petty Cash Reimbursement Voucher

Position Description

Post-Employment EEO/AA Form

Post-Employment Information of Veteran Status

Postal Service Nonprofit Standard Mail

Postal Service Postage Statement

Poster Service Request Form

Printing Services Service Request Form

Prior Approval Form

Property Deletion Request

Property Removal Permit

Property Transfer Request

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Quick Reference Guide

Reconciliation Log

Research Scope of Practice for Study Personnel

Research Study Patient Enrollment Form

Records Disposition Log

Release Form

Reserved Purchase Order, Request for

Request for Accounting of Disclosures

Request for Amendment of Health Information

Request for Approval to Recruit

Request for Approval to Recruit for Vice Presidents

Request for Approval to Recruit - UTMSA

Request for Approval and Payment to Employee for Additional Services

Request for Approval of Outside Employment, Consultation, or Related Activities

Request for Confidential Communications Regarding Medical Information

Request for Transfer of Records to University Archives

Restriction Request Form

Revocation of Authorization to Release Protected Health Information

Room Reservation Request

Room Reservation Request (Edinburg only)

Room Reservation Request (Harlingen only)

Room Reservation Request (Laredo only)

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Security Background and Sanction Check, Authorization for

Selection of Student Employee Form

Sequencing Request Form

Service on Outside Boards

Sick Leave Pool Physician Statement

Sick Leave Pool Request

Sick Leave Pool Voluntary Contribution Form

Signature Authority for Property Inventory Records

Social Security Numbers - Approved Notices for Disclosure of

Sole Source Proprietary Justification for Products

Sole Source Proprietary Justification for Services

Software Deletion Request

Space Management Processing Flow Chart

Space Planning Form

Space Request Form

Special Event Parking Request Form/Worksheet

State Sales Tax Exemption Certificate

Student Travel Authorization

Student Travel Information and Release Form

Subject Payment Form

Subject Payments Schedule

Suggestion Form, Staff Advisory Council

Supplemental Payment to Faculty

Supplemental Report of Injury

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Telecommuting Agreement

Transfer of Funds Request Form

Transgenic Services Request Form

Travel Contractor Usage Statement, State of Texas

Travel to Washington, D.C. - OSFR Official Form

Traveler Profile

Travel Voucher

UT Police Department Work Order Form (UTPD-WOF)

Vendor/Payee Set Up Form

W-4 Form for IRS

Workers' Compensation Leave of Absence

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