Forms


Returns you to HR's home page.


A reference for employees of the Medina County Board of Commissioners


Departments reporting to the Medina County Board of Commissioners.


Links to EAP & Work/Life Program information and services.


A variety of on-line forms for departmental use.


Useful information covering a wide range of topics.


County Commissioners' Home Page

 

These on-line forms are available for your convenience.
 
SAFETY RELATED FORMS
 

       Form A - Incident/Injury Report

       Form C - Incident Follow-Up

       FROI - First Report of Occupational Injury (BWC)

       Medical Release of Information   (C101)

       Notice of Loss - Property or Vehicle 

       Map of Urgicare Facilities
FMLA FORMS

                        FMLA Policy

    Request for Leave 

    Medical Certification (Employee) Form

    Medical Certification (Family Member) Form

    Eligibility and Rights Form

    Designation Notice Form

TRAVEL RELATED FORMS
           Travel Reimbursement Policy 7.085 

     Travel Request Form 

    Travel Expense Record 
EMPLOYEE EVALUATION FORMS

    Self Appraisal Form 

    Performance Appraisal Form 

EMPLOYMENT

        Employment Application (PDF) 
         
           SSA-1945 (PDF)

Section 419(c) of Public Law 108-203, the Social Security Protection Act of 2004, requires State and local government employers to disclose the effect of the Windfall Elimination Provision and the Government Pension Offset to employees hired on or after January 1, 2005, in jobs not covered by Social Security. This particular law requires newly hired public employees to sign a statement that they are aware of a possible reduction in their future Social Security benefit entitlement.