Employee Forms

Change of Address Form - use this form for name and/or address changes

Fiscal Forms


Direct Deposit - please include a copy of your VOIDED check in order to sign up for Direct Deposit

W-4 - 2017

Emergency Payroll Advance Request

Payroll Change Form

Accounts Payable

Accounts Payable Direct Deposit - for employee mileage reimbursements, travel or any other non-payroll payments

W-9 Form


New Employee Member Enrollment Form

Appeal Form - You may appeal to OEBB about dependent eligibility decisions, enrollment errors and omissions, Healthy Futures, or missed enrollment timelines.

Opt Out Form - In accordance with the participation requirements for OEBB opt-out provisions, OAR 111-040-0050 and the District's association agreements, members who elect not to participate in the OEBB Health Plan including medical, pharmacy, dental and vision coverage wil be entitled to receive a monthly financial incentive.

Mid-Year Change Form

Beneficiary Form

Health and Safety Forms


SAIF/801 Form - fillable - form must be opened in Adobe to enable fillable feature

Short Term Disability (STD)

American Fidelity

Standard STD


Request for unpaid absence


OFLA/FMLA request form

Health Care Provider Certification

Fitness for Duty Questionnaire



Douglas Education Service District | 1871 NE Stephens | Roseburg, OR 97470
Telephone: 541.440.4777 | Fax: 541.440.4771

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