Matt Blunt, Governor - Larry Schepker, Commissioner

 

 

 

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UNIVERSAL FORMS INDEX

(The SAM II forms listed below are to be used when you do not have access to the online SAM II system.)

Accounting Central Accident Reporting Miscellaneous Personnel Purchasing Secretary of State - Records Management State Treasurer

SAM II Accounts Receivable, Cash Revenue SAM II Budget Control SAM II Chart of Account SAM II Cost Allocation SAM II Expenditures Disbursements SAM II Federal Aid Management SAM II Fixed Asset

SAM II General Accounting SAM II Inventory SAM II Job Costing SAM II Policy and Procedure Manual SAM II Project Accounting SAM II Purchasing SAM II Security

AGENCY FORMS INDEX

DOA, Agriculture DOA, Animal Health DOA, Fuel Quality DOA, State Milk Board DOA, Plant Industries DOA, Weights and Measures DOC, Corrections DED, Economic Development DED, Community Development DED, Credit Unions DED, Family Development DED, Missouri Arts Council DED, Neighborhood Assistance Program DED, Public Service Commission DED, Prof. Registration - Architects DED, Prof. Registration - Embalmers/Funeral Dir DED, Prof. Registration - Healing Arts DED, Youth Opportunities DHE, Higher Education

DHSS, Health and Senior Services DHSS, Aging DMH, Mental Health DMH, Fulton State Hospital DMH, Mental Retardation and Dev. Disabilities DMH, Mid-Missouri Mental Health Center DMH, Nevada Habilitation Center DMH, Northwest MO Psychiatric Rehabilitation Center DMH, Southeast MO Mental Health Ctr. DMH, Southwest MO Psychiatric Rehab Ctr. DMH, St. Louis Psychiatric Rehabilitation Center DMH, Western MO Mental Health Ctr. DNR, Natural Resources DNR, Air Pollution DNR, Geology and Land Survey DNR, Solid Waste DNR, Water Pollution DOR, Revenue DOR, Drivers License Bureau

DPS, Alcohol and Tobacco Control DPS, Missouri Veterans Commission DSS, Social Services DSS, Children's Division DSS, Child Support Enforcement DSS, Family Support Division DSS, Legal Services DSS, Medical Services DSS, MOHealthNet DSS, Rehab. Services for the Blind DSS, Youth Services MDI, Insurance MoDOT, Transportation Carrier Services MoDOT, Transportation Right of Way Office of Administration OA, Design and Construction OA, Ethics Commission OA, State Data Center OA, State Printing Center

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UNIVERSAL FORMS INDEX

(The SAM II forms listed below are to be used when you do not have access to the online SAM II system.)

Accounting Forms - Universal

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All Forms in Accounting Group - Universal

Inventory Additions, Transfers, Dispositions and Changes (3/96) Monthly Expense Report, 3 Pt (4/06) *Standard Rate .455 per mile / Fleet Rate .250 per mile Monthly Expense Report, 4 Pt (4/06) *Standard Rate .455 per mile / Fleet Rate .250 per mile Out of State Travel Authorization (4/01) Back to Top

Payroll Direct Deposit Application (12/07) Postage Voucher (9/01) Supplemental Check/Check Cancellation Request (2/02) Warrant Request for Non-Appropriated Funds (10/98)

Central Accident Reporting Forms - Universal

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All Forms in CARO Group - Universal

Accident on State Property - Loss Notice (Non-Vehicle)(10/02) Auth. to Release Medical Records - Workers' Compensation (11/06) Automobile Loss Notice (10/02) Early Return to Work - Physical Assessment (5/02) Early Return to Work Temporary Modified - Duty Assignment (12/01) Employee Injury Report - Workers' Compensation (8/05) Back to Top

Eyeglasses Report (3/03) Initial Injury Report (Form O) (7/05) Mileage Reimbursement Request (7/05) Supervisor Statement (10/07) Time Lost Report for Workers' Compensation Injuries (10/98) Witness Statement (3/03)

Miscellaneous Forms - Universal

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All Forms In Miscellaneous Group - Universal

After-Hours Access/State ID Badge (12/06) Agency Security Request (6/00) Caregiver Background Screening (8/02) Employee of the Month Nomination (8/98) Facsimile Transmittal (5/99) Facsimile Transmittal - No Confidentiality Notice (8/94) Form Input Sheet (3/98) Form Input Sheet Instructions (PDF File) Back to Top

Program Decision Item Analysis Form 5 (8/98) Redistribution Authorization (4/98) Report of State Owned Surplus Property (9/04) Requisition for State Forms and Paper (4/98) Service Order (6/98) Systems/Programming Service Request (5/98) Work Request/Change Order (5/98)

Personnel Forms - Universal

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All Forms In Personnel Group - Universal

Career Progression Promotion (1/99) Employee Performance Log (3/98) Performance Appraisal Summary (5/02) Performance Planning and Appraisal (4/01) Back to Top

Performance Planning and Appraisal (Continuation) (3/98) Personnel Change Request (8/00) Personnel Requisition and Certification (3/98)

Purchasing Forms - Universal

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All Forms In Purchasing Group - Universal

Bid Record (8/01) Bid Record Continuation (8/01) Domestic Products Procurement Act (Buy American) (5/05) Local Purchase Order (2/08) Back to Top

Request for Document (7/98) Request for Quotation (11/03) Request for Quotation Continuation (5/99)

Secretary of State - Universal

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Travel (3/08)
Tuition Pre-Approval and Reimbursement (2/08)

Secretary of State - Records Management Forms - Universal

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All Forms In Records Management Group - Universal

Microfilm Work Order Request (4/03) Records Box Labels (3/98) Records Transmittal and Receipt (3/98) Back to Top

Records Transmittal and Receipt Continuation (3/98) Request for Records Disposition Authority (4/98)

State Treasurer - Universal

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Affidavit for Forgery (8/00)

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SAM II Forms - Accounts Receivable, Cash Revenue

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All Forms In SAM II AR, Cash Revenue Group

Accounts Receivable Billing Profile (BPRO) (3/99) Accounts Receivable Credit Memo (RM) (3/99) Accounts Receivable Customer Code Maintenance (CUST/CUS2/TXT) (4/99) Accounts Receivable Documents (RE) (4/99) Accounts Receivable Documents (RE) Accounting Details Continuation (4/99) Accounts Receivable Documents (RERE) Accounting Details Continuation (4/99) Accounts Receivable Master Service Agreement (MSAT) And Associated Open Receivable Options (OREO) (4/99) Accounts Receivable Open Receivable Options (OREO) (3/99) Accounts Receivable Open Receivable Text (RETX) (3/99) Accounts Receivable Payment Schedule (PSHD) (5/99) Accounts Receivable Recurring Receivable (RERE) (5/99) Accounts Receivable Renewal Notice Scheduling (RNEW) (5/99) Accounts Receivable Renewal Notice Text (RTXT) (4/99) Back to Top

Accounts Receivable Renwal Type (RNTP) (3/99) Accounts Receivable Revenue Options by Agency/Revenue Source (ROAR) (3/99) Accounts Receivable Third Party Billing (TPAR) (3/99) Accounts Receivable Warrant Intercept (WINT) (3/99) Cash Receipt (CR) (5/99) Cash Receipt (CR)/Quick Cash Rec. (CRQ) Continuation (7/99) Cash Receipt Quick (CRQ) (4/99) Collection Notice (6/99) IAB Payment/Receipt (CRP) (10/99) Invoice (6/99) Multi-Payee Payment Voucher (PVV) (8/99) Non-Sufficient Funds (NF) (4/99) Renewal Notice (6/99) Statement (6/99)

SAM II Forms - Budget Control

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All Forms In SAM II Budget Control Group

Agency Reserve (AR) (3/99) Allotment Document (AL) (3/99) Appropriation Document (AP) (3/99) Expense Budget (EB) (2/99) Back to Top

Revenue Budget (RB) (3/99) Transfer Appropriation (TA) (2/99) Transfer Budget (TB) (3/99)

SAM II Forms - Chart of Accounts

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All Forms In SAM II Chart of Account Group

Activity (ACT2) (2/99) Activity Rollup (2/99) Agency (AGC2) (2/99) Agency Rollup (3/99) Balance Sheet Account (BAC2) (3/99) Balance Sheet Account Rollup (2/99) Bank Account (BANK) (2/99) Budget Object Budget Class (BOBC) (4/99) Function (FUNC) (2/99) Function Rollup (2/99) Back to Top

Fund (FUN2) (3/99) Fund Agency (FGY2) (2/99) Fund Rollup (2/99) Object (OBJ2) (3/99) Object Rollup (2/99) Organization (ORG2) (3/99) Revenue Source (RSR2) (4/99) Revenue Source Rollup (2/99)

SAM II Forms - Cost Allocation

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All Forms In SAM II Cost Allocation Group

Allocation Group Control Reference (ALLC) (2/99) Cost Allocation Account Type (CAAT) (2/99) Cost Allocation Distribution Options (CADO) (2/99) Back to Top

Pool/Base Definition/Reference (PBDF) (2/99) Pool/Base Definition Reference (Variable Method (PBDA) (3/99)

SAM II Forms - Expenditures Disbursements

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All Forms In SAM II Expenditures Disbursements Group

Check Cancellation (CX) (4/04) Expense Payment Voucher (PVE) (5/01) Manual Warrant (MW) (3/99) Multiple Vendor Payment Voucher (MP) (4/01) Quick Payment Voucher (PVQ) (5/01) Quick Payment Voucher (PVQ) Continuation (5/01) Back to Top

Recurring Journal Voucher (REJV) (3/99) Recurring Payment Voucher (REPV) (3/99) Special Payment Voucher (PVS) (5/01) Vendor ACH/EFT Application (8/03)  Use for Vendor Updates Vendor Payment Voucher (P1) (5/01)

SAM II Forms - Federal Aid Management

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All Forms In SAM II Federal Aid Management Group

Basis Code Definition (BAS2) (4/99) Drawdown Request Dates (DRQD) (4/99) Federal Agency (FEAG) (4/99) Federal Aid Charge (FX) (5/99) Federal Aid Inference (FAIT) (4/99) Back to Top

Federal Aid Master (FM) (3/99) Federal Aid Status (FAST) (4/99) Incorrect Cost Percentage Entry (ICPE) (4/99) Reporting Category (RPTG) (4/99)

SAM II Forms - Fixed Asset

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All Forms In SAM II Fixed Asset Group

Acquisition/Disposition (FADM) (8/99) Condition/Last Inventory Date Update (FADU) (2/99) Fixed Asset Acquisition (FA) (3/08) Fixed Asset Catalog (FCLG) (2/99) Fixed Asset Disposition (FD) (2/99) Fixed Asset Group Rollup (3/08) Fixed Asset Location Rollup (2/99) Back to Top

Fixed Asset Location Rollup (2/99) Fixed Asset Modification (FC) (3/08) Fixed Asset Reorganization (FARO) (8/99) Fixed Asset Transfer (FT) (3/99) Fixed Asset Type (FATP) (2/99) Fixed Asset Valuation (FVAL) (8/99) Manual Depreciation Input (MDEP) (3/08)

SAM II Forms - General Accounting

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All Forms In SAM II General Accounting Group

Batch Header (3/99) Journal Voucher (JV) (6/99) Monthly Expense Report, 3 Pt (4/06) *Standard Rate .455 per mile / Fleet Rate .250 per mile Back to Top

Monthly Expense Report, 4 Pt (4/06) *Standard Rate .455 per mile / Fleet Rate .250 per mile SAM II System Reports Distribution Request (10/99)

SAM II Forms - Inventory

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All Forms In SAM II Inventory Group

Adjustment Code (ADJC) (3/99) Commodity Code Request (COMT) (4/99) Current Period Crew Timesheet (CREW) (6/00) Current Period Individual Timesheet (CITS) (6/00) Inventory Adjustment (IA) (4/99) Inventory Inquiry (INV3) (4/99) Over the Counter (OC)/Manufacturing Over the Counter (MC) (4/99) Back to Top

Physical Inventory Process (4/99) Return Code (RETC) (4/99) Stock Requisition (SR) (4/99) Stock Return (SN)/Manufactured Items Receipt (MN) (4/99) Stock Transfer Issue (TI)/Stock Transfer Receipt (TR) (4/99) Warehouse Management (WHS2) (5/99)

SAM II Forms - Job Costing

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All Forms In SAM II Job Costing Group

Job Charge (JC) (3/99) Job Control (JB)/(JBR) MODOT Project (6/99) Job Organization (8/99) Back to Top

SAM II Forms - Policy and Procedure Manual

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All Forms In SAM II Policy and Procedure Manual Group

SAM II Policy and Procedures Change Request (11/99) SAM II Policy and Procedures Change Track (11/99) Back to Top

SAM II Forms - Project Accounting

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All Forms In SAM II Project Accounting Group

Charge Class (CHRG) (3/99) Project Budget (PB) (8/99) Project Charge (PX) (3/99) Project Management Master (PJ)/(PJR) MODOT Project (6/99) Back to Top

Project Phase (PRPH) (3/99) Project Status Code (PRST) (3/99) Sub-Project Description (SPDT) (3/99)

SAM II Forms - Purchasing

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All Forms In SAM II Purchasing Group

Non Pre-Encumbering Requisition (NR) (4/99) Non Pre-Encumbering Requisition (NR) Commodity Details/Text Continuation (4/99) Price Agreement Master Document (AM) (5/99) Price Agreement Master Document (AM) Commodity Text Continuation (5/99) Price Agreement Master Document (AM) PA Text Continuation (5/99) Price Agreement Master Document (AM) Vendor/Commodity Continuation (5/99) Quick Decentralized Purchase Order (PDQ) (5/00) Quick Decentralized Purchase Order (PDQ) Accounting Details Continuation (3/99) Quick Decentralized Purchase Order (PDQ) Commodity Details/Text Continuation (4/99) Quick Price Agreement (PGQ) Order (5/00) Quick Price Agreement (PGQ) Order Accounting Details Continuation (5/99) Quick Price Agreement (PGQ) Order Commodity Details/Text Continuation (5/99) Back to Top

Quick Requisition (RXQ) (4/99) Quick Requisition (RXQ) Accounting Details Continuation (5/99) Quick Requisition (RXQ) Commodity Details/Text Continuation (4/99) Quick Vendor Invoice (VIQ) (7/01) Receiver (RC) (4/99) Service Contract (SC) Order (5/00) Service Contract (SC) Accounting Detail Order Continuation (4/99) Service Contract (SC) Order Commodity Detail/Text Continuation (4/99) Simplified Service Contract (SCS) (4/00) Simplified Service Contract (SCS) Accounting Details Continuation (4/99) Simplified Service Contract (SCS) Commodity Details/Text Continuation (4/99) Vendor Input (5/07)

SAM II Forms - Security

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All Forms In SAM II Security Group

SAM II Financial Agency Security Request (11/03) SAM II Financial Central Processing Security Request (OA, STO, SAO and DOR ONLY) (11/03) SAM II HR Security Request (3/08) Workflow Request (6/95) Back to Top

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AGENCY FORMS

Agriculture Universal Forms

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All Forms In Agriculture Universal Group

Activity Report - Fuel Quality Program (10/02) Daily Usage Log Report (5/01) Open Meeting Notice (5/01) Performance Improvement Plan (1/01) Personnel Action Request (9/03) Back to Top

Performance Management Work Plan and Discussion (5/01) Print Requisition Record (7/01) Record of Performance (1/01) Request for New or Replacement Employee (5/96)

Agriculture - Animal Health Forms

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All Forms In Agriculture Animal Health Forms Group

ACFA - License/Registration Application (10/07) ACFA - Per Capita Worksheet (10/07) Agreement for Performance of Livestock Market/Sale Vet Resp. (4/00) Animal Care Inspection Worksheet (5/01) Animal Care Program Inquiry (2/01) Application for Brand Registration (5/98) Destruction (3/02) Compliance Activity Report (4/02) Consumer Inquiry Information Sheet (6/02) Evidence Log (2/08) Exhibit Cover Sheet (1/08) Exempt Establishment Inspection Report (Continuation) (8/07) Exempt Establishment Inspection Report (Meat/Poultry Operations) (8/07) Individual Certified Herd Plan (11/00) In-Plant Performance Stystem Assessment Sheet(8/07) Inspection Report (8/98) Inter-Departmental Communication(6/96) Livestock Dealer Application (9/02) Livestock Market/Sale Inspection Report (1/00) Back to Top

Market/Sale License Application Noncompliance Record (8/07) Notice of Detention (3/02) Notice of Termination of Detention (3/02) Offical Warning - Violation of State Regulations (5/01) Photographic Log Sheet (2/08) Plant Profile (HAACP) (2/01) Program Inquiry Review Work Sheet (8/97) Program of Veterinary Care - Req for All Licenses (10/99) Property Receipt (6/02) Qualified-Psuedorabies Free Swine Herd Plan (5/00) Release (2/01) Release from Official Plant of Inedible/Condemned Animal Products (2/01) Report of Apparent Violation (6/02) Review and Compliance Record (6/02) Shipper's or Receiver's Certification (6/02) Uniform Methods - BLV (10/01) Validated-Brucellosis Free Swine Herd Plan (5/00) Weekly Field Activity Report (11/02)

Agriculture - Fuel Quality Forms

Notice of Violation (12/04) Back to Top

Agriculture - Plant Industries Forms

Notice of Inspection/Inspection Report (6/00) Back to Top

Agriculture - State Milk Board Forms

Application for Bulk Milk Hauler License (8/05) Distributor's Report of Receipts & Utilization (1/07) Milk and Milk Product Volume and Fee Report (9/07) Missouri Antibiotic Report (1/07) Tester-Grader-Sampler License Application (1/07) Back to Top

Agriculture - Weights and Measures Forms

Stop Sale Notice (10/04) Back to Top

Corrections Forms

Departmental Request for Purchase (9/01) Departmental Request for Purchase - Continuation (7/97) Vendor Information Data (2/05) Back to Top

Economic Development Universal Forms

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All Forms In Economic Development Universal Group

Annual Activity Report for Municipalities (1/01) Application for Private Activity Bond Allocation (7/01) Certificate (1/01) Departmental Work Request (10/96) Dry Fire Hydrant - Request for Transfer (3/00) Dry Fire Hydrant Tax Credit Application Pre-Application (12/99) Dry Fire Hydrant - Tax Credit Certification (3/00) Dry Fire Hydrant - Tax Credit Claim (12/99) Feedback Conference Summary (12/04) IDC Annual Activity Report(1/01) Job Requirements (12/04) Back to Top

Leave Record (5/95) Leave Share Application (6/99) Leave Share Donation (4/00) Medical Practioner's Statement (4/01) Miscellaneous Expense Reimbursement (8/06) Monthly Expense Report (9/06) *Std Rate .455/mile - Reduced Rate .250/mile Performance Development Plan (12/04) Purchase Request (8/06) Report of Private Activity Bond Issuance (1/01) State Vehicle Request (12/98)

Economic Development Forms - Community Development

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Historic Tax Credit (3/01) Historic Preservaton Tax Credit and NPA Tax Credit - Prelim. Approval (9/02) MOCAPP Form A - Resolution (2/05) MOCAPP Form B - Vision Statement (2/05) MOCAPP Form C - Mission Statement (2/05) MOCAPP Form D - Organizational Chart (2/05) MOCAPP Form E1 - Sub. Organizational Chart (HR) (2/05) MOCAPP Form E2 - Sub. Organizational Chart (ED) (2/05) MOCAPP Form E3 - Sub. Organizational Chart (GO) (2/05) Back to Top

MOCAPP Form E4 - Sub. Organizational Chart (CS) (2/05) MOCAPP Form E5 - Sub. Organizational Chart (CF) (2/05) MOCAPP Form F1-F37 - Sub. Mission Statements (2/05) MOCAPP Form G1-G37 - Local Available Resources (2/05) MOCAPP Form H1-H37 - Asset Mapping (2/05) MOCAPP Form I1-I37 - Goal Setting (2/05) MOCAPP Form J1-J37 - Comparison of Subcategory Standards (2/05) MOCAPP Form K - Sub. Prioritization of Goals (2/05) MOCAPP Form L - Individual Goal Worksheet (2/05)

Economic Development Forms - Credit Unions

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Official Acknowledgement of Corp Officers for Fiscal Year (12/01) Back to Top

Economic Development Forms - Family Development

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Application for Claiming Tax Credits (2/03) Back to Top

Economic Development Forms - Missouri Arts Council

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Grant Agreement (6/07) Grant Amendment (11/07) Public Broadcasting Grant Agreement (6/07) Back to Top

Economic Development Forms - Neighborhood Assistance Program

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Application for Claiming Tax Credits (2/03) NAP Budget Amendment(8/01) NAP Final Report(8/01) NAP FY2004 Project Application (12/02) Back to Top

NAP Local Government Certification(12/98) NAP Project Extension Request(8/01) NAP Quarterly Report(8/01)

Economic Development Forms - Public Service Commission

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All Forms In Public Service Commission Group

Absence from Office (8/99) Annual Attendance Record (1/01) Applicant Contact Sheet (12/02) Application for Computer-Based Training (5/02) Application for Share Leave (4/00) Application for Seminar Enrollment (8/02) Application for Tuition Assistance (1/03) Auth. for Release of Medical Information (11/99) Background Investigation Consent (12/01) Certification of Registration (12/03) Computer Software Request (9/04) Data Information Request (9/98) Declaration of Prof Licenses, Certifications and Org Memberships (8/07) Directed Prof/Technical Training Agreement (10/03) Dress Code Waiver (6/00) EFIS Change Order Request (8/02) Emergency Notification (5/06) Employee Data (8/06) Employee Exit Questionnaire (8/00) Employee Flex Time Request (9/03) Employee Handbook (6/07) Employee Suggestion (11/99) Employee Tuition Reimbursement Request (4/00) Expense Account Checklist (5/01) Feedback Conference Summary (10/03) Feedback Conference Summary - Probationary (10/03) FMLA Criteria (12/03) Grievance Review Request (4/00) Back to Top

Health Care Provider Certification (9/03) Hiring File Checklist (10/05) Hiring Recommendation (6/05) Internal Complaint (5/00) Interview Report (8/00) Inventory of Non-Expendable Items Assigned to Employee (11/99) Job Requirements (5/00) Medical Practitioner's Statement (4/00) Motor Vehicle Record (12/02) Oath of Office (6/06) Performance Development Plan (6/00) Physical Fitness Participation Request (3/02) Pre-Employment Reference Check (5/00) Publication Request (11/00) References (6/99) Representation of Independence (6/05) Scanning Request (9/02) Secondary Employment Disclosure (11/06) Seminar Evaluation (4/00) Share Leave Donation (5/02) State Vehicle Request (8/99) Statutes of Missouri (8/99) Temporary Employee Hiring Recommendation (9/06) Transfer of Leave Balance and Creditable Service ((3/02) Vacancy File Checklist (10/05) Verbal Discussion (8/00) Written Reprimand (8/00)

Economic Development Forms - Professional Registration - Architects/Engineers/Land Surveyors

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Form titles in red require latest version of setup files.

All Forms In Professional Registration Architects/Engineers/Land Surveyors Group

Affidavit to Amend - Architectual (4/03) Affidavit to Amend - Land Surveying (4/03) Affidavit to Amend - Professional Engineering (4/03) Application for a Corporate Certificate of Auth.(4/03) Application for a Corporate Certificate of Auth. - Limited Liablity(4/03) Application for Approval of Corporate Name Application for Duplicate Corporate License/Framing Cert (8/02) Application for Duplicate Enrollment Card Application for Duplicate License/Framing Cert. Certificate of Authority - Land Surveying (4/03) Certificate of Authority - Professional Engineering (4/03) Certificate of Authority - Architectual (4/03) Change of Address (7/02) Change of Name Affidavit Examination Experience Log - Architectural (5/03) Back to Top

Application Packets - Must be downloaded separately Application for Enrollment at Land Surveyor-In-Training (2/03) Application for Lisensure as a Landscape Architect (1/03) Application for Registration as Architect (5/03) Application to Enroll as Engineer Intern (2/03) Application to Enroll as Engineer Intern (NAEG) Application to Register as Professional Engineer (11/03) Application to Register as Professional Engineer (NAEG) Application to Register as Professional Land Surveyor (4-03) Application to Register as Professional Land Surveyor (Sect 327.391 RSMo) (6/02) Application to Register as Land Surveyor in Training

Economic Development Forms - Professional Registration - Embalmers/Funeral Directors

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All Forms In Professional Registration - Embalmers/Funeral Directors Group

Affidavit of Practical Work - Embalmers (8/00) Affidavit of Practical Work - Funeral Directors (8/00) Back to Top

Economic Development Forms - Professional Registration - Healing Arts

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Application for Physical Therapy Asst Licensure (4/04) Application for Physical Therapy Licensure (11/03) Athletic Trainer Registration Application (6/04) Back to Top

Auth for Release of Medical Information and Records (8/03) Original Documents - International Graduates Only (8/03)

Economic Development Forms - Youth Opportunities

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Application for Claiming Tax Credit (YOP) (9/01) Application for Claiming Tax Credits (2/03) Youth Opportunities Program Final Report (9/01) Back to Top

Higher Education - Universal

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Personnel Action Request (9/05) Back to Top

Health and Senior Services Forms - Universal

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Adult Head Injury Prior Authorization (12/07) Adult Head Injury Prior Authorization Modification (2/07) Authorization for Disclosure of Consumer Medical/Health Information (1/03) Client Assessment (5/07) Client Choice Statement (1/06) Cohort Presentation: Pulmonary/Extrapulmonary TB Case (6/06) Enrollment Information (4/07) Level of Determination (5/07) Personal Care/Advanced Personal Care Assessment (5/07) Participation Agreement for Prof/Special Services Provider (7/07) Back to Top

Physical Disabilities Waiver Plan of Care (5/07) Prior Authorization Request (11/06) Prior Authorization Request - Dental Services (8/06) Private Duty Nursing Aggreement (7/05) [DSS] Private Duty Nursing Assessment (8/06) Provider Application (8/07) Rights and Responsibilities (8/06) Tuberculosis Medication Record (6/06) Tuberculosis Testing Record (10/06) Tuberculosis Wksht for Contacts of Newly Diagnosed Cases (6/06)

Health and Senior Services Forms - Aging

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All Forms In Division of Aging Group

Affiliate List - Corporation (8/00) Affiliate List - LLC (8/00) Affiliate List - Non Profit Company (8/00) Affiliate List - Partnership (8/00) App. for License to Operate a Long Term Care Facility (12/97) Assurance of Compliance (8/00) Complaint Investigation Finding (12/96) Complaint Investigation Report (2/97) Complaint Report Identification (1/97) Corrections for LTC Facility License Agreement (5/00) Exhibits (6/90) Back to Top

Forecasted Income Statement (1/96) Noncancelable Escrow Account (9/00) Nursing Home Surety Bond (8/00) Relicensure Financial Info. Statement - Gen. Business (3/96) Relicensure Financial Info. Statement - Sole Proprietor (1/96) Report of Change (4/00) Statement of Deficiencies (DA-110) (9/96) Statement of Deficiencies (DA-110A) (9/96) Statement of Financial Condition (1/96) Statement of Financial Position (1/96)

Health and Senior Services Forms - Senior Services

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Alzheimer's Special Care Services Disclosure (2/03) Back to Top

Insurance Forms Universal

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State Vehicle Operation Log (9/06)

Additional Info Request - Bail Bond Agent (8/06) Additional Info Request - Bail Bond Agent Renewal (8/06) Additional Info Request - Business Entity Producer (8/06) Additional Info Request - Producer (8/06) Additional Info Request - Producer Renewal (8/06) Additional Info Request - Public Adjuster/Solicitor (8/06) Additional Info Request - Surplus Lines (8/06) Affidavit of Exam Proctor (10/05) Change of General Bail Bond Status (10/05) Back to Top

Change of Surety Recovery Agent Status (10/05) Continuing Education Provider - Additional Info Request (8/06) General Bail Bond Affidavit (10/05) Mo Uniform App for Bail Bond/Surety Recovery License [Form B1](9/06) Mo Uniform App for Misc Individual/Corporate License (10/05) Mo Uniform Renewal App for Bail Bond/Surety Recovery License [Form BR] (12/06)

Mental Health Forms

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All Forms In Mental Health Group

ACI Quarterly Report (10/07)  Accounting Distribution Sheet (5/00) Accurate Intake and Output Record (7/00) Actvity Therapy Assessment (2/87) ADA Certification (4/98) Affidavit in Support of App for Detention, Evaluation and Treatment/Rehab (96 Hours) (8/00) Aftercare Plan (9/00) Aftercare Plan (1/99) Aftercare Plan Continuation Sheet (1/01) Aftercare Plan Continuation With Lines (4/99) Annual Review Physical Examination (7/00) Annual Settlement Request (9/87) Applicant File Information (8/99) Application/Contract for Educational Stipend (12/04) Application for Admission by Legal Guardian (10/98) Application for Determination of Conflicting Employment/Conflict of Interest (1/03) Application for Tuition Reimbursement (3/02) Application for Voluntary Inpatient Admission Application for 96 Hour Detention, Evaluation and Treatment/Rehab of a Voluntary Patient Request Release (8/07) Application for 96 Hour Imminent Harm Admission (8/07) Application to Court for 96 Hour Detention/Evaluation and Treatment/Rehabilitation (8/07) Attachment A/Pricing Page (4/99) Audio and Visual Equipment Request (11/03) Authorization for Disclosure of Consumer Medical/Health Information (1/03) Authorization for Property Release (7/04) Authorization for Reimbursement of Interim Asst. Initial Payment (1/02) Authorization for Release of Confidential Information (2/99) Authorization to Discuss Confidential Client Information (9/98) Authorization to Release Confidential Client Information (1/00) Certificate of Account (1/05) Children's Services Treatment Plan (6/01) Choices for Families Program Invoice (2/99) Choices for Families Voucher (2/99) Client Movement(8/00) Clinical Utilization Review Request(9/05) College Credit and GED Courses (3/98) Community Placement Data Sheet (8/99) Community Placement Funding Authorization (9/00) Community Placement Program Services Invoice (12/98) Community Placement Summary (4/95) Compulsive Gambling Treatment Status and Outcomes Review (11/01) Conditional Release for Involuntarily Detailed Patient (8/00) Consent and Agreement for SCL Services: Children and Youth (8/97) Consumer Incident Report - Pilot (5/02) Contract Amendment (2/99) Contract Information (8/99) Contract Service Key Data (8/99) Contracts/Amendments Route Slip (11/00) Consent and Authorization (11/00) CPS Adult Status Report (12/07) Daily Attendance/Break Record (9/00) Delivery Performance (7/97) Diet List (9/00) Diet Order Card (7/00) Direct Billing Authorization Request (5/02) Direct Deposit Sign Up (7/97) Discharge Summary (1/99) Dispersement of Deceased Patient's Personal Account in Absence of RLA (11/01) Employee Training Record (8/98) Expense and Equipment Requisition (10/98) Facility Justifcation for Approval of Educational Stipend Application ( 12/04) Family Friend Services - Monthly Documentation (8/99) Field Determination (10/01) Financial Information Inquiry (2/99) Financial Information Transmittal (1/99) Fire Evacuation Drill (7/00) Fiscal Year Vehicle/Equipment Cost and Use Report (9/01) Food Costs - Report A (8/98) Forensic Notification (10/98) Grant Application Funding Request (8/02) Grievance - Client (10/03) HCFA-1500 Health Insurance Claim Form (8/99) Hepatitis B Immunization (10/00) Back to Top

Incident and Investigation Tracking System Report (3/02) Index Crime Report (4/99) Individual Treatment/Rehabilitation Plan (5/99) Individual Treatment/Rehabilitation Plan (8/05) Individual Treatment/Rehabilitation Plan Continuation (8/05) Individualized Supported Living Resid. Budget Plan (3/03) Informational Transmittal (2/99) Integrated Risk Assessment (7/98) Interfacility Transfer Memo (2/99) Labor Costs - Report B (5/02) List of Witnesses (8/96) Medicare Beneficiary Admission Questions (4/99) Meeting Notes (4/01) Membership Application (12/07) Monthly Travel Documentation (8/99) Non-Appropriated Fund Check Authorization (2/99) Notice and Consent for Early Intervention Services (9/02) Notice and Consent for Multidisciplinary Evaluation (2/99) Notice of Admission of Involuntary Patient (3/02) Notice of Cost (1/99) Notice of Discharge/Voluntary Admission (4/01) Notice of Discharge/Voluntary Admission (1/00) Notice of Rights of Involuntary Patient (2/00) Nutrition Screening Q.A. Worksheet (1/03) Nutrition Screening Quality Improvement Summary Report (11/00) Nutritional Assessment (12/98) Ophthalmic Record (7/00) Order Authorizing Admission of Ward to Mental Health Facility (1/00) Parent/Guardian Request for SCL Services: Children and Youth (8/97) Performance Improvement Plan (10/05) Person Centered Plan - Task/Skill Objective (7/00) Personnel Action Request/Budget Approval (11/07) Petition for Involuntary Detention and Treatment (8/07) Petition to Admit Ward (1/00) Physical Examination (5/99) Physical Therapy Requisition (3/97) POS Contract Service Key Data (8/99) Prescription (9/00) Prevention Services Payment Invoice (6/01) Progress Notes (9/99) Progress Notes With Lines (10/98) Prognosis Request Psychological Assessment (11/93) Purchase of Service Invoice (3/00) Purchase of Service Payment Invoice (3/00) Purchase of Services Invoice Adjustment (4/00) Quality Improvement Monitoring (4/98) Quarterly Review (1/99) Questionnaire for Employees Who Are Leaving (7/99) Receiving Report of Nonexpendable Property (10/99) Record of Visits and Passes (7/00) Request for Change of Venue (2/96) Request for Expenditure (1/08) Request for Proposal Route Slip (11/00) Requisition (9/00) Review Notes (4/02) Review of Competency to Stand Trial (8/01) Review of Systems (6/02) RFP/Contracts/Amendment Route Slip (8/99) Seizure Activity Report (9/00) Seizure Progress Entries (7/00) Serious Incident History Worksheet (11/98) Slot Movement Request (9/01) Social Service Assessment (11/99) Special Precautions Flow Sheet (11/02) Standard Means Test Financial Questionnaire (1/99) Subpoena/Return (2/96) Support Activity Report (4/99) Time and Attendance - Input Record (2/01) Trial Visit (2/96) Tuition Reimbursement Request for Payment (1/01) Vacation Schedule (3/97) Vehicle Trip Ticket (9/00) Verification (5/00) Weight Record (7/00) Withdrawal Petition (9/95) Witness Statement (2/96) Workshops, Seminars and Conferences (3/02)

Mental Health Forms - Fulton State Hospital

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All Forms in Fulton State Hospital

Absence Notice Absences for 24 Hour Period Absenteeism Report Accounting Department Storage Receipt Activity Therapy Assessment (3/06) Activity Therapy Assessment Checklist (9/04) Activity Therapy Daily Attendance Record Admission Face Sheet Worksheet Admission Medical/Psychiatric Assessment Reports Adolescent Restraint/Seclusion (8/06) Adult Restraint/Seclusion (8/06) Advanced Directives (8/05) Ambulance Dispatch Sheet Annual Employee Competency Profile Annual Synopsis of Endangering Behaivor Annual Volunteer Assessment (4/04) Antimicrobial Order Form (8/05) Appearance/Room/Shower Check (1/96) Applicant Checklist Application for SCL Services Attendance Confirmation Authentication Certification (11/07) Batch Ticket Bid Unsuccessful Notice Box Lunch Order Form (4-07) Brief Trauma Assessment (5-06) Canteen Receiving Report Cardiac Enzymes Request Cart Correction Sheet (12/05) Census Report - Biggs Forensic Center Certificate of Account - FSH Chaplaincy Service Screening CIMOR Incident Report (Facility) (7/07) CIMOR Injury Report (Facility) (7/07) Client Movement Report (Facility) (10/07) Client Services - Individual Clothing Fair Tally Sheet College Credit and GED Courses Tuition Reimbursement Communications Services Credit Request Community Placement Summary Consent to Audio-Video Taping and/or Photography of Patients Consent to Blood/Body Fluid Samples Course Evaluation - Hospital Wide Orientation Crisis Intervention Stabilization Program Cummulative Summary of Frequencies/Tokens for Daily Sheets Current Worker's Compensation Cases (10/05) Daily Cash Reconciliation Daily Census Report (11/06) Daily Check Off - Environmental Services Daily Check Out (12/06) Daily Client Movement Log (5/07) Daily Controlled Drug Dispensing Summary Daily Group Movement Log (4/07) Department Meeting Minutes Diagnosis Update (10/98) Diet Requisition Dietary Order/Issue Report Direct Care Employees Request for Payment (4-06) Discharge/Aftercare Plan (1-06) Discharge Summary - SCL (3/03) Distribution Sheet for Benefit Doctor's Orders - Medicine Doctor's Orders - Medicine Admission PRN Medication (5/06) Doctor's Orders - Treatment Doctor's Orders - Treatment Preprint (11-05) Easy Glucometer Testing (8/00) Employee Checklist (6/04) Employee of the Month Nomination Employee Performance and Appraisal Employee Relations Committee Voucher Employment Application (10/06) Employment Record Environmental Rounds Env Serv Quality Control Inspection (10-05) Escort Medical Facilities Eye Record Eye Worksheet (5/06) Face Sheet Update Fast Performance Process Monitoring Fire Drill Report (7/07) Food Request for Employee/Visitor Functions (8/03) Forensic Assessment For Privileges and Passes Forensic Notification Forensic Patient Transfer GFC Appearance Checks GFC Room Checks Granting of a Bid - Official Notice Grievance - Consumer (11/06) Group/Volunteer Events Guardianship Review Hazard Supply Issued HazMat Hazardous Materials Report Hope Center (4/06) HPC Ward Shakedown Index Crime Report Individual Assignment Rating and Pay Day Initial Activity Therapy Assessment (8/05) Initial RN Suicidal Assessment Initial/Update Nursing Admission Assessment (5/07) Ink Pen Sign Out/In - Male Inservice Education Record (3/03) Integtrated Risk Assessment Internet Log Investigative Screening Investigative Screening Witness Statement Job Order Request Job Safety Analysis Key Request (11/03) Legal Guardian Consent for Necessary Medical Treatment (10/02) Light Duty Assignment Leave Request Leisure Events Weekly Tally Library Subscription Record Master Summary Request Mealtime Observation Assessment (4/07) Medical Equipment Initial Inspection (10/06) Medical Services Request (Sick Call) (12/05) Medically Indicated Transfer Medication Error/Medication Near Miss Report (Facility) (7/07) Medication Error Review Medication Reconciliation (2/06) Medication Reconciliation Continuation (5/06) Missing - Escape/Return Report Back to Top

Monitoring Review Documentation of Time Out Monthly Competency Verification Due List Move Request Approval Multidisciplinary Progress Note: Competency Education Class (10/07) New Employee Assessment New Employee Check-In (6/05) New Employee Checkoff List (7/05) New Worker Checklist Notice of Protest (10/01) Notice of Resignation/Transfer (3/06) Nursing Flow Sheet (1-05) Nursing Flow Sheet (Miscellaneous) (11-96) Nursing Q.I. Audits Nutrition Note Nutritional Screening (12/04) Official Bid Sheet On Ward Jobs Open Positions to Post for Bidding Outcome List (8/05) PA/SA/Train Tech/LPN Required Classes Pain Management Monitoring Pain Documentation Flow Sheet Patient and/or Staff Food Parties Patient Assignments Patient Face Checklist (2/06) Patient Transfer/Referral (11/07) Patient Worker Time Summary Patient's Monthly Wages Patient's Request for Expenditure of Funds (11/03) Paycheck Sign Sheet Payroll Time Personal Safety Plan (4/06) Pharmacy Drug Reorder (12/06) Pharmacy Return/Credit (4/96) Physician Consultation Physician Services - Inpatient (3/05) Physician's Progress Notes (8/95) Physician's Verification of Sick Leave Postage Report (4-05) Postage Usage Daily By Department Precaution Flow Sheet (1/03) Print Shop Report Program Screening Guide (6/92) Programming Request Purchase Order Purchasing/Issue Requisition (9/99) Psychological Services - Inpatient Psychology Service Psychosocial Rehabilitation Program Informal Interaction Quality Assurance/Improvement Presentation Report (5/06) Quarterly Review - SCL Questionnaire for Tuition Recent Predictive Behaivors Record of Information Released Rehabilitation Services Consultation and Referral (10/02) Report of Adverse Drug Reaction (11/07) Request for Purchase of Services/Devices Request for Quotation Requistion for Food Supplies (8/05) Restraint/Seclusion Notification (11/05) Risk For Fall Assessment (8/02) Risk of Choking Assessment (11/07) RN Monthly Summary (2/06) RN Progress Note: Suicidal 1:1 and Close Observation (3/07) RN Required Classes and Competencies SCL - Facility Review SCL - Movement Memo (3/03) SCL - Nursing Assessment Seclusion/Restraint (Initial) (5/07) Seclusion/Restraint Continuation (5/07) Seclusion/Restraint Debriefing (2/06) Seclusion/Restraint Flowsheet (9/06) Second Generation Antipsychotic Medication (8/06) Security Check List Security Chronological Log (1/05) Security Violations Serious Incident History Worksheet Sharp Count Shift Report - Environmental Services Shift Report - Nursing (11/06) Showers/Baths Daily (11/06) Significant Events Social Service Assessment Social Service Preliminary Assessment (4/06) Special Funding Request Speech Pathology Assessment Speech Pathology Hearing Screening Staff Assistance/Support Debriefing Tool (6/06) Staff Support Response Monitoring Checklist Statement of Patient's Rights Steam Power Production (4/04) Substance Abuse Assessnment (4-06) Summaries of Monies Received From (2-07) Summary of Frequencies/Tokens of Weekly Sheets Supervisor's Checklist for Inducting the New Worker