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DOH Forms

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Name	Form Number	Lead Organization	Description/ Instructions
6 Month Equipment Evaluation		Equipment	Show 6 Month Equipment Evaluation
Assignment of Future Wages		Human Resources	Show Effective: 12/1/2006 APPLICATION: The Assignment of Future Wages form allows employee who have received their initial Temporary Total Disability Benefits (TTD) check to reimburse his or her employer the net value of sick and/or annual leave benefits paid through payroll deductions. Finance Division Payroll section completes this form and forwards it to the employee for signature and notarization.
Cost Report Form		Legal	Show
Daily Work Record SC-477			Show
DBE CONTRACTOR'S PERFORMANCE REPORT			Show
Equipment Operator Accounability Policy		Equipment	Show
Excess Hours Reporting Form			Show
New Equipment Evaluation		Equipment	Show New Equipment Evaluation
Order Form for Proposals, Plans & X-Sections		Contract Administration	Show Order Form for Proposals, Plans & X-Sections Republished: 11/1/2000 APPLICATION: The Order Form for Proposals, Plans & X-Sections is completed by Contract Administration Division, or by the requesting vendor, for each request received. Computer entries are made from the information recorded on the form, after which it is forwarded with an Invoice (Form BF-38) to Finance Division for further processing.
Overtime Worked/Emergency Worksheet		Maintenance	Show Overtime Worked/Emergency Worksheet
Report of Motor Vehicle Accident (AR-13)			Show
Safety Awards Nominations Form			Show
Salvage Yard Application		Traffic	Show
Scheduled Overtime Worksheet		Maintenance	Show Scheduled Overtime Worksheet
Worker's Compensation Declination Form		Human Resources	Show
Workers' Compensation Declination to File Workers’ Compensation (BrickStreet Insurance) Claim Form		Human Resources	Show Workers' Compensation Declination to File Workers’ Compensation (BrickStreet Insurance) Claim Form
Workers' Compensation Temporary Total Disability Benefits or Sick Leave Benefits Election of Option		Human Resources	Show Workers' Compensation Temporary Total Disability Benefits or Sick Leave Benefits Election of Option Effective: 12/1/2006 APPLICATION: The Election of Option form allows employees, who have suffered a compensable work-related injury, to elect the option of receiving sick leave or Temporary Total Disability Benefits (TTD). Once completed, the original is sent to Highways' Human Resources for transmission to BrickStreet.
Employees in Attendance	AH-01	Human Resources	Show Employees in Attendance Effective: 9/1/2001 APPLICATION: The Employees in Attendance Form is used to record the names (and other pertinent information) of employees in attendance at meetings, seminars, and workshops sponsored by the Division of Highways. These forms must be completed (by the instructor or participants) and signed by the instructor at each session. Completed forms are submitted to Human Resources Division at the conclusion of the event.
Employee Evaluation Form (training course)	AH-03	Human Resources	Show Employee Evaluation Form Republished: 11/1/2000 APPLICATION: Each attendee at DOH-sponsored training sessions, conferences, seminars, etc., will complete this form at the end of the event. It is used to collect the attendees' opinions of the effectiveness and other qualities of the meeting.
Overall Rating Form (training course)	AH-04	Human Resources	Show Overall Rating Form Republished: 11/1/2000 APPLICATION: The AH-04 is a tally sheet used to collect and organize the information submitted on AH-03 Forms. It is completed by the organization in charge of the training session, meeting, seminar, or conference, at the end of the event, and submitted to Human Resources Division.
Employee Verification (salary)	AW-508	Human Resources	Show Employee Verification Republished: 11/1/2000 APPLICATION: Form AW-508, Employee Verification, is completed by new DOH salaried employees who have previous tenure with the DOH or any other agency that the DOH recognizes for tenure purposes. It is submitted, ultimately, to the Payroll Section of Finance Division, where it is used to determine an employee's leave accrual rate and other tenure-based benefit eligibility. The form must be notarized to be valid.
Employee Verification (hourly)	AW-509	Human Resources	Show Employee Verification Republished: 11/1/2000 APPLICATION: Form AW-509, Employee Verification, is completed by new DOH hourly employees who have previous tenure with the DOH or any other agency that the DOH recognizes for tenure purposes. It is submitted, ultimately, to the Payroll Section of Finance Division, where it is used to determine an employee's leave accrual rate and other tenure-based benefit eligibility. The form must be notarized to be valid.
PAYROLL TRANSACTION - PARKING DEDUCTION (BF-129P)	BF-129P	Finance	Show Payroll Transaction Form (Parking) Effective: 7/1/2001 APPLICATION: The BF-129P is used by DOH employees who work at the Capitol Complex in Charleston to authorize or to cancel a payroll deduction for parking space rental. The completed form is submitted to Office Services Division who, in turn, submits it to the Payroll Section of Finance Division.
Receipts Account Deposit Ticket Log	BF-140	Finance	Show Receipts Account Deposit Ticket Log Republished: 11/1/2000 APPLICATION: The BF-140 is used by District and Central Office personnel to log deposits to one-way accounts. BF-140’s are received with their DOH Receipts Accounts Ticket. When a ticket is prepared, the necessary information is entered into the BF-140. Of the three copies of the deposit ticket, the last copy will be filed with the BF-140 at the organizational level.
Use of State Vehicle for Commuting	BF-155	Finance	Show Use of State Vehicle for Commuting Republished: 11/1/2000 APPLICATION: The BF-155, Use of State Vehicle for Commuting, is used to report when an employee must occasionally commute from the job site to his or her domicile using a state vehicle. The BF-155 is to be completed on a three-month basis (see schedule printed on form). The time that the vehicle was used for commuting as described above is recorded on the BF-155. SPECIAL INFORMATION: If car-pooling is involved in commuting as described above, each rider must file a BF-155.
Daily Permit and Map Sales Record	BF-23	Finance	Show Daily Permit and Map Sales Record Effective: 6/15/2002 APPLICATION: The BF-23, Daily Permit and Map Sales Record, is used to log the sale of OH-16 permits and maps. To prepare the BF-23, the County Permit Clerk must first arrange the daily OH-16s in sequential order. Then, the necessary information is copied to the BF-23. Turnpike charges associated with permits are accounted for separately, in the "Turnpike Charges" column. A permit document package, including the original BF-23 and a copy, is transmitted to the District every Thursday. If $20 of permit fees is collected before Thursday, then the documents are transmitted on the day the $20 dollar limit is reached. The county files a copy of the BF-23. The District Permit Clerk must arrange the District's OH-16s in sequential order as well. The BF-23 is prepared and the document package concerning permits is mailed to Finance Division (via BF-56, Transmittal) every Friday. The document package contains the original and one copy of the BF-23. The District retains a copy for its files as well. Map sales are documented a week at a time on the BF-23 and on Friday the monies and original/one copy of the BF-23 are sent to Finance Division. Planning and Research Division retains a copy of the BF-23 for it's files.
Official Station Assignment	BF-30	Finance	Show Official Station Assignment Republished: 11/1/2000 APPLICATION: The BF-30, Official Station Assignment, form is completed by each District Administrator/Division Director or their designee for each employee that might be called upon to travel. This form is used to determine when an employee is eligible for travel reimbursement. Whenever an employee's assignment is changed, a new BF-30 must be completed, the Form BF-30A must be up-dated and Finance Division must be notified.
Official Station Assignment Log	BF-30A	Finance	Show Official Station Assignment Log Republished: 11/1/2000 APPLICATION: The BF-30A, Official Station Assignment Log, contains the information from the District/Division's BF-30 "Official Station Assignment" forms. It is compiled by the District Administrator/Division Director or their designee. The original of this log, listing each travel-oriented employee, is to be filed in Finance Division at the beginning of each calendar year (January 1). A copy is to be kept in the District/Division office file. If a change in the official station assignment of an employee occurs during the year, a memo must be submitted to Finance Division within 15 days after the change, requesting that the BF-30A be updated to reflect this change.
Transmittal	BF-56	Finance	Show Transmittal Effective: 6/15/2002 APPLICATION: The BF-56, Transmittal, is used by organizations to transmit BF-23 Daily Permit and Map Sales Record forms and the cash and checks recorded on the BF-23's to Finance Division.
Verbal Authorization	BF-98C	Finance	Show Verbal Authorization Republished: 11/1/2000 APPLICATION: The BF-98C is used by Highway Operations Division, Enforcement Division, or Finance Division, in conjunction with Program Administration Division, when issuing a verbal authorization. The Division Director of the issuing organization must sign and date the BF-98C prior to issuing a verbal authorization to the requesting organization. A verbal authorization is used when it is necessary to perform work prior to an approved authorization (BF-98) being issued, as in the case of an emergency or accident/claim in which a highway must be repaired prior to the proper identification of a claimant. The above agencies may issue a verbal authorization to begin necessary work immediately. Following this, a BF-98C must be completed and submitted to Finance Division. Issuance of a BF-98C does not preclude preparation of a BF-98 by the requesting organization. The original BF-98C must be transmitted to the Data Control Section of Finance Division by 2:00 PM on the day of issue. SPECIAL INFORMATION: Under "Distribution," the name of the organization requesting the Verbal Authorization and the names of any other organizations required to receive a copy of the BF-98C are entered. This distribution will be accomplished by the issuing organization.
Employee’s and Physician's Report of Injury	BI-1	Human Resources	Show Employee’s and Physician's Report of Injury Effective: 2/1/2006 APPLICATION: The Form BI-1 (formerly WC-1), Employee’s and Physician’s Report of Injury, is the official documentation to be completed by the employee (Section I) and physician (Section II) to report an occupational injury to BrickStreet Mutual Insurance Company. Contact Human Resources Division, Workers’ Compensation Section at 558-9775 for additional information.
Claim Reopening Application	BI-125	Human Resources	Show Claim Reopening Application Effective: 2/1/2006 APPLICATION: The Form BI-125 (formerly WC-125), Claim Reopening Application, consists of three separate sections and is the official documentation to reopen a workers’ compensation benefits claim. Section I will be completed by the applying employee. Section II is optional. If completed , it will be filled out by Human Resources. Section III will be completed by the attending medical staff. Contact Human Resources Division, Workers’ Compensation Section at 558-9775 for additional information.
Employer’s Report of Injury	BI-3	Human Resources	Show Employer’s Report of Injury Effective: 7/15/2006 APPLICATION: The Form BI-3 (formerly WC-3), Employer’s Report of Injury, is the official documentation to be used by the employer to report an occupational injury to BrickStreet Mutual Insurance Company. Personnel in the injured employee’s division district who are designated by the Human Resources Division complete this form. SPECIAL INFORMATION: Item number 2., Industrial Code, select the appropriate code from the pull down menu. Note: Date of injury must be entered prior to the Industrial Code. A listing of the available National council on Compensation Insurance, NCCI, Industrial Codes is located in DOH Administrative Operating Procedures Section II, Chapter 3, Appendix B.
Return to Work Notice	BI-309	Human Resources	Show Return to Work Notice Effective: 2/1/2006 APPLICATION: The Form BI-309 (formerly WC-309), Return to Work Notice, is completed by Human Resources and submitted when an injured employee who has been receiving workers’ compensation benefits returns to work.
Application for Outdoor Advertising License	DN-12	Traffic	Show
Operators Qualification Report	DOH-20	Human Resources	Show Operators Qualification Report Republished: 11/1/2000 APPLICATION: Supervisors of equipment operators will ensure that Form DOH-20, Operators Qualification Report, is completed, verifying which kinds of equipment operators are qualified to operate. Copies of the form will be distributed as required by management.
Long Distance Toll Calls	DOH-45	Finance	Show Long Distance Toll Calls Republished: 11/1/2000 APPLICATION: The DOH-45 Long Distance Toll Calls log is utilized by employees to record their DAIN OFF-NET long-distance calls. The DOH-45 is reconciled with the DAIN Telephone Listing computer report to determine which calls on the computer report are business and which are personal.
Request for Assignment of a DOH Transportation Vehicle	DOH-55	District/Division	Show Request for Assignment of a DOH Transportation Vehicle Republished: 11/1/2000 APPLICATION: The DOH-55, Request for Assignment of a DOH Transportation Vehicle, is used to document the circumstances and solicit the necessary approval for each "individually assigned vehicle." The DOH-55 is a single-part form that is normally completed, signed by the employee's supervisor and transmitted to the District Administrator/Division Director for approval. Provisions for higher-level managers' ("H," "C" and Commissioner's) authorization is also provided on the form in the event that the assignment will be an exception to the Commissioner's policy. All approved original DOH-55s are to be retained at the district or division headquarters with a photocopy sent to and retained at the assigned employee's organization. The maximum assignment period for any DOH-55 is one calendar year. Prior to the end of each calendar year, all employees with an individual vehicle assignment that must be continued into the coming year will complete a new DOH-55 and submit for approval. These year-to-year assignments will automatically become invalid unless a new DOH-55 has been approved and filed. Additionally, as noted on the bottom of the DOH-55, any change in the particulars of the approved assignment (that is, parking location, assignment period, reassignment of employee, etc.) will require the completion of another DOH-55 and submission for approval. Specific justification for each assignment must be documented on each DOH-55. The stated justification must coincide with that permitted in the commissioner's policy memorandum. If the assignment is to an employee specifically referenced by title or classification to be assigned a vehicle in the Commissioner's policy, then the justification is simply "By Commissioner's policy."
Building and Grounds Work Order	DOH-8	District/Division/Finance	Show Building and Grounds Work Order Republished: 11/1/2000 APPLICATION: The DOH-8, Building and Grounds Work Order, is a request for repairs and/or work to any DOH facility that is not a part of the highway system. It may be originated at any level, but it must be approved and signed by the section or organization supervisor. This individual then submits it to the District Building and Grounds organization for further review and an estimation of the total cost of the project. SPECIAL INFORMATION: If the estimated cost is under $1,000, a ten-digit work order number will be assigned, as prescribed in Section V, Chapter 12, and entered on the form. If the project is estimated to cost $1,000 or more, the authorization number assigned by Finance Division is used.
Roadside Memorial Sign Application	DT-57	Traffic	Show Roadside Memorial Sign Application
Underground Storage Tank Monitoring Log	GL-1	Equipment	Show Underground Storage Tank Monitoring Log Republished: 11/1/2000 APPLICATION: An individual, designated by management, will complete the GL-1 at each DOH location with underground storage tanks for fuel (pumps) each operating day, using the Pump Station Report (Form GL-2). On the last operating day of each month, the appropriate columns are totaled and the calculations performed, as per Section IV, Chapter 7 of these DOH Administrative Operating Procedures. Upon completion, the GL-1 is forwarded to Division/District Headquarters (with a copy remaining at the originating organization) and is maintained on file for a period as prescribed by the appropriate federal and state authorities.
Employment Form	GL-4	Human Resources	Show Employment Form Republished: 11/1/2000 APPLICATION: Form GL-4, Employment Form, is used to add information to the Personnel Data Processing System for a new employee. An organization's payroll/personnel clerk normally completes Section I of the GL-4 and submits it to the Division Director or District Administrator for review and approval. Immediately upon approval, it is submitted to Human Resources Division along with the Application for Examination and all other accompanying documentation needed to employ a permanent or temporary employee.. The Human Resources Division will, upon obtaining all appropriate approvals, return Form GL-4 to the hiring organization for completion.
Transaction Form	GL-5	Human Resources	Show Transaction Form Republished: 11/1/2000 APPLICATION: Form GL-5, Transaction Form, is used to change, correct, or add information to the Personnel Data Processing System which has been established for the Division of Highways. An organization's payroll/personnel clerk normally completes the GL-5 and submits it to the Division Director or District Administrator for review and approval. Immediately upon approval, it is submitted to Human Resources Division, so that the Personnel Data Processing System can be updated in a timely manner.
Interview Record	GL-541	Human Resources	Show Interview Record Republished: 11/1/2000 APPLICATION: Form GL-541 provides a record of an employment interview. It is filled out by the supervisor conducting the interview. Information for ""Position Applied for"" ""Job Location"" and ""Name"" (of person being inter-viewed), ""Ethnic Code,"" (note that the Ethnic Code is to be determined from the interviewer's observation, not from direct inquiry) and ""Bulletin No."" must be supplied by the supervisor filling out this form. The form is then retained in the Vacant Position folder."
Education/License/Skills Record	GL-6	Human Resources	Show GL-6 Education/License/Skills Record Republished: 11/1/2000 APPLICATION: Form GL-6 is to be completed by new employees, with assistance from the hiring organization's personnel/payroll clerk (if necessary). After completion, it is to be submitted (along with other "new hire" documentation) to Human Resources Division for entry into the Personnel Data Processing System.
Micro-Film Request	GS-41	Office Services	Show GL-541 Interview Record Republished: 11/1/2000 APPLICATION: Form GL-541 provides a record of an employment interview. It is filled out by the supervisor conducting the interview. Information for "Position Applied for" "Job Location" and "Name" (of person being inter-viewed), "Ethnic Code," (note that the Ethnic Code is to be determined from the interviewer's observation, not from direct inquiry) and "Bulletin No." must be supplied by the supervisor filling out this form. The form is then retained in the Vacant Position folder.
Employment Eligibility Verification	I-9	Human Resources	Show Employment Eligibility Verification Republished: 11/1/2000 APPLICATION: Form I-9 is required by federal law to verify an employee's identity and eligibility to be employed by the DOH. Section I of I-9 is completed by the employee, with appropriate documents to be presented to the supervisor within three days of employment. The supervisor must then complete Section II. The completed I-9 and documentation used to establish identity/ eligibility are then sent to Human Resources Division with the employee orientation. The division/district should maintain a copy of the I-9/identity-eligibility documentation.
Field Report Information	ME-114	Equipment	Show Field Report Information Republished: 11/1/2000 APPLICATION: When an organization modifies or retrofits an equipment unit, the ME-114 must be completed by the organization and submitted to the Director of Equipment Division. The Field Report Information form captures information to be used in reclassifying the equipment and assigning a new ED number.
Field Report Tank	ME-115	Equipment	Show
Equipment Purchases	MQ-39	Equipment	Show Field Report Information Republished: 11/1/2000 APPLICATION: The MQ-39 is used by the Equipment Division Accountant to report the value of a newly classified or reclassified equipment unit to Finance Division.
Permit Log	MT-66	Maintenance	Show Permit Log Republished: 11/1/2000 APPLICATION: The MT-66 allows the District Permit Clerk to record all information needed to control all permits in a district. It is the responsibility of the District Permit Clerk to update and maintain this log. As a permit (OH-16) is issued, it is recorded in the MT-66.
Fabrication Welding Verification	OE-200	Equipment	Show Fabrication Welding Verification Republished: 11/1/2000 APPLICATION: The OE-200 is completed whenever welding is involved in the fabrication or re-fabrication of a unit of equipment. It is signed and dated by all personnel performing the welding and submitted to the Director of Equipment Division.
Agency Bill of Sale	OE-90	Equipment	Show Agency Bill of Sale
Equipment Evaluation Form	OE-97	Equipment	Show Equipment Evaluation Form
Special Permit for Single Trip	OH-16	Maintenance	Show Special Permit for Single Trip Republished: 11/1/2000 APPLICATION: OH-16’s are completed by the County Permit Clerk, batched together with the BF-23’s (Daily Permit & Map Sales Record) , and submitted to the District Permit Clerk each Thursday (unless the monies and checks reach $20.00 prior to Thursday, in which case the transmittal should be made that day). Transmittal is made on Form BF-56. The money is also transmitted, via Form BF-58 (Cash Receipt). The applicant is given a copy of the OH-16 at the time of issuance. The District Permit Clerk, after submitting the money to the District Comptroller, submits the OH-16’s and other documents (with a copy of the receipt from the District Comptroller) to Finance Division, Accounts Payable Section. Copies of the OH-16s are also submitted to the Permits Section of Highway Operations Division.
Maintenance Schedule Worksheet	OM-41	Maintenance	Show Maintenance Schedule Worksheet Republished: 11/1/2000 APPLICATION: Form OM-41, Maintenance Schedule Worksheet, is a maintenance organization's work plan for one week. It includes the work to be done, the day(s) and time in which it is to be done, the number of workers needed together with the supervisor in charge, and the materials involved along with estimated quantities. The OM-41 is completed by the applicable Supervisor and posted on the organization's bulletin board two weeks in advance of the proposed work week. A copy must be submitted to the appropriate District Administrator for review. All revisions will be posted on the schedule as soon as possible. Each OM-41 will remain posted for one week after the scheduled work is done.
Changes to the State Highway System	OM-79	Maintenance	Show Changes to the State Highway System
Exit Survey	RL-507	Human Resources	Show Exit Survey Effective 4/15/2006 APPLICATION: Form RL-507, Exit Interview Survey, is used to document the reason an employee leaves employment with the DOH. RL-507 is completed by the employee during the exit process. The organizational clerk will return it directly to Human Resources Division on the same day as the notification of exit or as soon thereafter as possible. The division or district will not retain a copy of the exit survey.
Notice to Employee of Immediate Oral Suspension Followed by Written Notice and an Opportunity to Respond	RL-545	Human Resources	Show Notice to Employee of Immediate Oral Suspension Followed by Written Notice and an Opportunity to Respond Republished: 11/1/2000 APPLICATION: Form RL-545 is used to give notice to an employee of an immediate oral suspension. It must be prepared and signed at the direction of the Division Director/District Administrator. It should be served to the affected employee at the time of the oral suspension but, under extenuating circumstances, may be sent to the employee by registered mail no later than the next working day. Form RL-545 should be included in the disciplinary documentation sent to Human Resources Division.
Application and Interview Log	RL-551	Human Resources	Show Application and Interview Log
Hot-Laid Bituminous Concrete Project Cost	SM-100	Maintenance	Show Hot-Laid Bituminous Concrete Project Cost Republished: 11/1/2000 APPLICATION: The SM-100 is used by appropriate employees to compare price estimates of vendors bidding on hot-laid bituminous concrete projects. It is used as directed in Section V, Chapter 11 of these DOH Administrative Operating Procedures.
Aggregate - Low Bid Computation	SM-102	Maintenance	Show Aggregate - Low Bid Computation Republished: 11/1/2000 APPLICATION: The SM-102 is a worksheet for determining the vendor that has submitted the lowest bid on an aggregate contract. It is completed by the appropriate District personnel and submitted to the Procurement Section of Finance Division upon completion. A copy is retained at the District Office.
Statement of Acceptance	SM-93	Maintenance	Show Statement of Acceptance