Career Services





Contact Us

Main Campus
Student Union

Room 1533
Mail Stop 112
Phone: 419.530.4341
Fax:  419.530.4013

HSC Student Employment Paperwork


Forms required to employ Health Science Campus (HSC) student workers:

HSC Student New Hire Packet (all forms included) (for links to individual forms click here.) Please sign all paperwork and assemble in the following order.  Individual forms may also be found below.

  1. Ohio Department of Taxation - Employee's Withholding Exemption Certificate
  2. W-4 form - Students to complete this online, under MyUT employee tab
  3. Ohio Public Employee Retirement System (OPERS form):    a) Request for Optional Exemption As a Student;  OR  b) Enrollment-Personal History Record
  4. Statement Concerning Your Employment in a Job Not Covered by Social Security (SSA-1945)  (Use only if enrolling in OPERS)
  5. Direct Deposit - Students to complete this online, under MyUT employee tab
  6. Personal Information Form  (with VA and War Statement attached)
  7. I-9 Employment Eligibility Verification Form     IMPORTANT: Be sure that start date on the EPFA corresponds with the date on the I-9.  (Must have table of acceptable documents copied on back)
  8. Acknowledgement of receipt of Auditor of State fraud reporting system information
  9. General Orientation Checklist
  10. Pre-Employment Statement - Expected Behaviors 
  11. Employee Certification of Understanding Ethical Conduct Statement
  12. Invention Reporting and Assignment Obligations
  13. icare Attestation of Commitment
  14. Patients' Rights
  15. Impaired Licensed Independent Practitioners statement
  16. Authorization to Release Information
  17. Student Employee Health Screening Request Form
  18. Acknowledgement of receipt of Auditor of State fraud reporting system information

HSC Supervisors - Training Materials

To be reviewed with new student workers (Tip-create binder with all training materials for new students to review)

  1. UTMC Mission
  2. icare Learning Program and policy
  3. UT Policies and Facts PowerPoint
  4. Ethical Conduct Statement ("Booklet")  
  5. Standards of Conduct Policy # 3364-25-01
  6. Confidentiality of Patient Information (#3364-15-10)
  7. Infection Prevention and Control and Safety Tips
  8. UT Smoke-Free and Tobacco-Free Policy HSC (#3364-60-01)
  9. Equal Opportunity (Policy #3364-50-02)
  10. Sexual Harassment and other forms of harassment (Policy #3364-50-01)
  11. Responsible use (Policy #3364-65-05)
  12. Accreditation Process
  13. Sentinel & Adverse Events (Policy #3364-50-38)
  14. Patient Safety and/or Occurrence Reporting (Policy #3364-50-39)
  15. Complaint/Grievance Management (Policy #3364-100-60-1)
  16. Patient Rights and Responsibilities (Policy #3364-60-2)
  17. Patent Policy (Policy #3364-70-04)
  18. Rights to and interests in discoveries, inventions or patents - establishment of rules (Ohio Revised Code #3345.14)
  19. Pre-Employment Drug Testing (Policy #3364-25-17)

NOTE: Some of the forms are also available on Payroll or the Human Resources websites

Last Updated: 8/15/18