Business and Service Forms



Access Control Executive Designation Form

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)

ADA Request Form - Staff

Adjunct/Adjoint - President Letter-2017-2018

Adjunct/Adjoint - President Letter-2018-2019

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 for Security Background Check

Authorization of Signature, Request for


Benefits Forms

Billing for Studies Involving Human Subjects

Bookstore Textbook and Manual Request Form

Business Card Request Form

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Canvas ASC User Access Form

Canvas Course Cross-Listing Request

Canvas Development or ASC Course Request

Canvas New Faculty or Staff Form

Card Access Request

Cash Receipt Deposit Voucher

Certificate of Proposal

Change of Chairman or Head

Chemical Waste Pickup Request

Clinical Faculty Appt Form

Clinical Faculty - President Letter

Clinical Trial Study Information to UT Medicine

Communications Service Request Form

Computer Exam Scoring Form Key

Confidentiality/Security Acknowledgement

Consent and Agreement for Treatment

Contractors and Vendors ID Request Form

Course Evaluation Request Form

Credit Card Merchant Request

Criminal Records Check Information Form 

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Data Use Agreement

Departmental Postage Request

Departure for International Visitors, Confirmation of

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

Employer's First Report of Injury or Illness

Exam Scoring Request Form

Expenditure/Deposit Transfer and Transaction Correction

Export Control Certification

Extension of Stay, Request for

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Fabricated Property, Record of

Facilities Management Request Work Online

Faculty Adjunct Adjoint

Faculty Appointment

Faculty Biographical Data Sheet

Faculty Promotion/Tenure Packet Checklist/Contents

Faculty Recruitment Report

Fitness for Duty Certification

FMLA - Certification for a Serious Health Condition - Employee

FMLA - Certification for a Serious Health Condition - Family Member

FMLA - Certification for Servicemember Serious Injury/Illness

FMLA - Certification of Exigency for Military Leave

FMLA - Request and Notice Form

Fellowship (Stipend) Award Authorization

Flex Time, Request for

Gift Log

Grants, NIH Modular Budget for HSC Internal Use

Hazard Assessment Request for Minors in the Workplace Form

HIPAA Patient Privacy Forms

Human Subjects Letter to NIH

Hybridoma Facility Service Request Form

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Information Management and Services Service Request Form

Instrumentation Services Service Request Form

Inter-Department Transfer Voucher

International Travel to High Risk Areas Waiver Request


I-9 Employment Eligibility Verification

Item Course Evaluation Requisition Form

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Key Request

Lease of Building Space Informational Questionnaire

Letter for Misdirected Fax

Letter of Intent to Establish a Consortium Agreement Template
       - applicable to proposals submitted to DHHS agencies)

Letter of Intent to Establish a Consortium Agreement Template
       - applicable to proposals submitted to non-DHHS agencies)

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

Local/State Voucher

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Management Oversight Questionnaire

Medical Treatment Authorization Form

Memorandum of Understanding for Faculty with VA-UTHSCSA Joint Appointments

Minors Conducting Research in the UTHSCSA Workplace Assessment

Minors in the workplace Video

Model Authorization Release Form

Monthly Time Report

Multimedia Production Services Service Request Form

Name Change Form - Former Employees

Notification of Faculty Vacancy

Notification of an On-the-Job Injury

OES Access Request Form

OSP Cash Voucher

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Panic Alarm Request

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

Policy on Transportation Form

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

Proof of Personal Insurance Coverage Form

Property Deletion Request

Property Removal Permit

Property Transfer Request

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Quick Reference Guide

Reconciliation Log

Records Disposition Log

Records Inventory Sheet

Release and Indemnification Agreement for Minors Form

Release Form - Patient Information

Release Form - Model Authorization

Research Scope of Practice for Study Personnel

Research Study Patient Enrollment Form

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 External Employment, Consulting, Board Membership, or Related Activities

Request for Confidential Communications Regarding Medical Information

Request for Transfer of Records to University Archives

Request to Close Project

Request to Close Project Instructions

Restriction Request Form

Revocation of Authorization to Release Protected Health Information

Room Reservation Request

Room Reservation Request (Laredo only)

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Sequencing Request Form

Service on Outside Boards

Sick Leave Donation - Donor

Sick Leave Donation - Recipient

Sick Leave Pool Physician Statement

Sick Leave Pool Request

Sick Leave Pool - Voluntary Contribution

Signature Authority for Property Inventory Records

Social Security Numbers - Approved Notices for Disclosure of

Software Deletion Request

Space Management Processing Flow Chart

Space Planning Form

Space Request Form

Special Event Parking and Police Services

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

Timesheet for Non-Exempt Employees

Transfer of Funds Request Form

Transportation Policy Form

Transgenic Services Request Form

Travel Contractor Usage Statement, State of Texas

Travel Voucher Form

Tuition paid by one PID

Tuition paid by multiple PIDs

UT Police Department Separation Form

Vendor Direct Deposit Authorization Form

Visitor Application Form

W-4 Form for IRS

Workers' Compensation Leave of Absence

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