Directors Office

 
ADA Task Force
ADA Grievance Form
ADA Notice
ADA Task Force Charter
 
Public Guidance Documents, Rules and Regulations
Contracts for Personal Services, Title 12, Chapter 1, Department of Administrative Services, Rules and Regulations Concerning the Approval of
Guidance Document Request Form
Nebraska State Government International Relations Policy
Accounting
Social Security Bureau, Title 10, Department of Administrative Services, Administration Rules and Regulations
Building Division
Building Division Rules and Regulations, Title 7
Capital Construction Projects Manual
External Leasing Manual
Leasing Privately Owned Real Property, Title 7, Chapter 2
Parking Manual
Creation of Building Safety Division
Materiel Division
Materiel Division Rules and Regulations, Title 9
Vendor Application and Instructions
Vendor Manual
Risk Management
State Claims Board Rules and Regulations
Transportation Services Bureau
Transportation Services Bureau Rules and Regulations, Title 8
 
Office of the Capitol Commission
Use of the State Capitol, Lincoln, Nebraska, State Capital, Title 6, Office of the Capitol Commission, Rules and Regulations Governing
Campaigning Guidelines
Drone and UAV Guidelines
Exterior Lighting Guidelines
Family Photo Guidelines
First Floor Display Guidelines
Leafletting Guidelines
News Conference Guidelines
Printed Material Distribution Guidelines
Promenade Deck Access Guidelines
Rally Guidelines
Second Floor Rotunda Program Guidelines
Smoking Guidelines
Wedding Guidelines
Wedding Photography Guidelines

 

Accounting

 
MANUALS
Accounting Manual
 Accounts Payable
2024 Expense Reimbursement Doc - EFFECTIVE 1-1-2024 - XLSX
Accounts Payable Warrant Cancellation Form
ERD Training Video
Fund Application - PDF
Investment Authorization - PDF
Petty Cash Fund Application- PDF
Request for Stop Pay-Replacement Warrant Form
State of Nebraska W9 - PDF
State of Nebraska Form 13 - PDF
Warrant Cancellation Certification - PDF
 Interims
Interim Payroll Information
Payroll Certification Mini-Manual
Mini-Manual
Payroll Certification Form Instructions - DOC
Payroll Certification Form - XLS
Payroll Certification Checklist - PDF
Payroll Processing Schedules
2024 Payroll Processing Schedule - Biweekly - PDF
2024 Payroll Processing Schedule - Monthly - PDF
2023 Payroll Processing Schedule - Biweekly - PDF
2023 Payroll Processing Schedule - Monthly - PDF
2022 Payroll Processing Schedule - Biweekly - PDF
2022 Payroll Processing Schedule - Monthly - PDF
Payroll Hours in Calendar or Fiscal Year - XLS
Payroll Forms - Employer
Employer Report of Special Payments - PDF
Instructions for the Payroll Calculation Form
Interim Direct Payment Worksheet - XLSX
Interim Worksheet - XLSM
Payroll Calculation Form - XLSX
Payroll Certification Checklist - PDF
Payroll Certification Form - XLS
Payroll Certification Form Instructions - DOC
Service Date Adjustment Form - XLSX
W2 Reprint Request Form - PDF
W4 E1 Instructions - PDF
Payroll Forms - Employee
Direct Deposit Enrollment Form - PDF
Employee Electronic Receipt of Form W-2 - PDF
Payroll Calculation Tables
Retirement Estimator

 

Internal Control

Internal Control Guidance
Internal Control Tools
Self-Assessment Tools
Other Tools

 

Master Lease

Master Lease Purchase Program

 

Purchasing Card

Purchasing Card Program

Budget

Publications
Federal COVID-19 Supplemental Appropriation
(April 2020 | YouTube)
Federal COVID-19 Supplemental Appropriations PowerPoint
(UPDATED June 3, 2020 | PDF)
Funding Provided to Nebraska for COVID-19
(UPDATED June 3, 2020 | PDF)
Initial Guidance for Local Government Requests for Reimbursement for COVID-19 Related Expenses
(June 10, 2020 | PDF)
COVID-19 Expenditure Tracking Memo
PDF | April 2020
Federal Funding Guidance Memo to All Agencies, Boards and Commissions
PDF | March 24, 2020
Federal Grant Award Summary Spreadsheet
March 24, 2020
Federal HHS COVID-19 Grant Awards
NASBO Website
NEMA – COVID-19 Status of Funds
Nebraska Coordinating Commission for Postsecondary Education – Postsecondary Education COVID-19 Related Information
U.S. Department of Treasury – Assistance for Small Businesses
Federal HHS COVID-19 Grant Awards
U.S. Department of Treasury - Coronavirus Relief Fund Information

 Building

Construction
Capital Construction Manual
State Building Plan Room
Builders Bureau, Lincoln, NE
Omaha Exchange Builders, Omaha, NE
Design
Design and Construction manual
Project Request form
Space requirement worksheet
Design standards examples
Leasing
External Leasing Manual
Lease Requisition Form - Blank
Facility Use Manual
Parking
Parking Manual
Parking Application
Vehicle Updates, Additional AVI Stickers, and Permits
Parking Exit Form
Bike Room Application
Visitor Parking Request Form
Handicapped Accessible Parking Request
Parking Rates and Fees
Tax Exemption Parking Plan
Car Pool Registration
Instructions on how to place AVI sticker
List of Vehicles with Metallized Windshield List
Vacant BLDGS & Excess Land(VBEL)
VBEL Request Form
VBEL Quarterly Meeting Agenda

 DAS Human Resources

 

Human Resources Shared Services ("HRSS")

These forms are internally created for State of Nebraska Human Resources Shared Services (“HRSS”) and are intended for HRSS Customer Agencies only. No State of Nebraska Agency is required to use these forms unless otherwise instructed.

American's with Disabilities Act (ADA) Accommodations
Healthcare Provider Reasonable Accommodation Form
Reasonable Accommodation Checklist for Teammates
Reasonable Accommodation Request Form
Family and Medical Leave (FMLA) and Leave Without Pay (LWOP)
FMLA Information for Leaders
Medical Leave Request Form
Teammate Medical Leave Request Checklist-Guide
Off-Boarding/Exiting Teammate Information
Knowledge Transfer Questionnaire
Off-Boarding Process Workflow
Return of State Property Form
Teammate Resignation Guide
Teammate Retirement Guide
Teammate Transfer Guide
On-Boarding/New Hire Information
OnBoarding Process Workflow
Orientation Process Workflow
Welcome Packet 1.0
Payroll
2023 Bi-Weekly Payroll Calendar
2023 Monthly Payroll Calendar
2023 Comp-Time or Overtime Election Form
Performance Management
Coaching -Documentation Form - Non Disciplinary
Direct Conversations - Guide
Performance Management Checklist - Leader
Non-Disciplinary Performance Improvement Plan - PIP
Providing Effective Feedback - Guide
Setting Expectations - Guide
Recruitment
Advanced Hire Rate Request Workflow
Competency-Based Interview Question Collection
New Requisition Questionnaire
New SOS Requisition Questionnaire
Recruitment Process Workflow
SOS Recruitment Process Workflow
Teammate Resources
SMART Goals Guidance-Template
Tuition Reimbursement
Tuition Reimbursement Application
Tuition Reimbursement Checklist for Teammates
Workday Help
Create and Monitor a Help Center Case - User Guide
Finding Help Articles - User Guide
Working Out of Classification
Working Out of Class Request Form
Workplace Injury/Workers' Compensation
Employee Incident Report Form
Workability Form
Lost Hours Spreadsheet
Teammate Injury Checklist and Guide
Supervisor Investigation Report
Witness Report Form
 

Employee Relations

Labor Contract Information
Discipline and Grievance Information
Leave & Workplace Resources
Training

PowerPoints and Handouts

Leader's Guide to Discipline (pdf)

Discipline Training (pdf)

FMLA Powerpoint (pptx)

FMLA Road Map (PDF)

Leave Training (PDF)

ADA Amendments (ppt)

2019-2021 NAPE Contract Training(PDF)

2019-2021 FOP Contract Training (PDF)

 Materiel

STATE PURCHASING BUREAU
Description Last Revised Format
Vendor Application 12/14/2020 Excel
Vendor Manual 12/14/2017 PDF
Nebraska W-9 and ACH Form 02/01/2019 PDF
Attestation Form 8/18/2014 PDF
State Purchasing Bureau Records Request Form 10/1/2019 PDF

Policies and Procedures

Description Last Revised Format
PROCUREMENT CERTIFICATION GUIDE: Workday Learning Navigation 1/18/2024 PDF
Unrestricted Open Market Purchase Authority Letter 6/30/2023 PDF
State of Nebraska Procurement Manual - For Procurements Posted Before 11/20/2023 9/14/2018 PDF
State of Nebraska Procurement Manual (NEW) - For Procurements Posted 11/20/2023 and after 11/20/2023 PDF
U.S. Flag Purchase Policy 01/04/2022 PDF
SPB Policy 23-01 - PCard & Purchases under $5,000 06/16/2023 PDF
SPB Policy 23-02 - Procurement Certification Program 11/20/2023 PDF
SPB Policy 23-03 - Contract Responsibility & Negotiations 11/20/2023 PDF
SPB Policy 23-04 - Scoring and Evaluation 11/20/2023 PDF
SPB Policy 23-05 - Contract Duration, Renewals & Extensions 11/20/2023 PDF
SPB Policy 23-06 - Exceptions/Deviations & Direct Purchase Authority 11/20/2023 PDF
SPB Policy 23-07 - Protest Policy 11/20/2023 PDF
SPB Policy 23-08 - Suspension & Debarment 11/20/2023 PDF
SPB Policy 23-09 - Prohibition on Purchasing from Vendors that Boycott Israel 11/29/2023 PDF
Contract Manager Handbook 5/28/2020 PDF
Contract Administration Plan (CAP) 12/8/2016 PDF
Two-Way Match Policy 3/30/2006 PDF
Preference Policies 10/1/2008 PDF

Other General Information

Description Last Revised Format
Request to Increase E1 Contract Quantity Form 3/28/2018 XLS
E1 Approval Route Worksheet 9/18/2017 Word
National Institute of Governmental Purchasing (NIGP) Codes 7/18/2017 XLS
Pre-Approved IT Items for Purchase (OCIO website) 7/1/2022 PDF
MMCAP Pharmaceutical Information 4/17/2017 PDF
Purchase Order Terms and Conditions 10/1/2020 PDF
Market Research Powerpoint 11/29/2016 PPT
Contract Location Report 7/2/2018 XLS
Processing Time Goals 11/2/2023 PDF

Exceptions/Deviations and Emergency Procurements

Description Last Revised Format
Deviation Requests from Contractual Services and Emergency Contracts Process PowerPoint 11/02/2023 PPT
Procurement Exception/Deviation Form (Form GS-1) 11/20/2023 PDF

Proof of Need Analysis Information

Description Last Revised Format
Proof of Need Analysis Guide 2/27/2020 Word
Proof of Need Analysis Template 2/27/2020 Word
Proof of Need Analysis Checklist for Agencies 2/27/2020 Word

Personal Services Guide

Description Last Revised Format
Personal Services Guide Template 7/14/2015 Word

Vendor Performance

Description Format
Vendor Performance Program Link

ODP Solutions / Office Depot Contract Information

Description Last Revised Format
ODP Solutions Account Application 8/15/2023  PDF
On-Line Return Instructions 8/15/2023 PDF
Return Authorization Form 8/15/2023  PDF

Moving and Installation Services Information

Description Last Revised Format
Agency Instructions for Office Relocations 1/15/2021 PDF
Moving and Installation Services Guide 1/15/2021 PDF
Procurement Training Guide Generating PO Moving and Installation Services 2/3/2021 PDF
Example Installation Services Quote Form 1/15/2021 XLS
Example Moving Services Quote Form 1/15/2021 XLS
Moving Services Quote Form 1/7/2021 XLS
Description Last Revised Format
Processing Timeline for Services 11/2/2023 Excel

RFI Boilerplate

Description Last Revised Format
Request for Information (RFI) Boilerplate (Form S-2) 9/25/2017 Word

RFP Boilerplates and Forms

Description Last Revised Format
Request for Proposal (RFP) Boilerplate (Form S-1) 3/29/2023 Word
Boilerplate Changes 2/3/2023 PDF
Request for Proposal (RFP) Checklist (Form S-3) 1/19/2024 PDF
Pre-Agreement Outcome Tool (Form S-4) 01/16/2024 Word
Solicitation Announcement Letter 7/22/2015 Word
Public Notice Cover and Announcement (Lincoln Journal Star/Beatrice Daily Sun Public Notice Form) 11/8/2018 Word
Pre-Proposal Attendance Sheet 10/16/2014 Word
Pre-Proposal Conference Questions 6/4/2014 Word
Addendum - Questions and Answers 9/23/2015 Word
Addendum - Addendum to RFP 10/16/2014 Word
Addendum - Change of Scope 10/16/2014 Word
Addendum - Schedule of Events Change 10/16/2014 Word
Addendum to Contract 7/21/2015 Word
Amendment to Contract 7/21/2015 Word
Respondents List 10/16/2014 Word
Intent to Award Letter 10/16/2014 Word
Rejection of Proposals 10/16/2014 Word
Mandatory Requirements Checklist 10/16/2014 XLS
Request for Fax or Electronic Quote 8/25/2014 XLS

RFP Evaluation and Scoring

Description Last Revised Format
RFP Evaluation and Scoring Manual for Services 1/26/2017 Word
Evaluator Agreement (Form GS-2) - (formerly Conflict of Interest Declaration) 11/20/2023 Word
Procurement Collaborator Agreement (Form GS-3) 11/20/2023 Word
Evaluator Scoring Worksheet 10/16/2014 Word
Evaluation Criteria 7/30/2015 Word
Cost Proposal Evaluation Worksheet 1/8/2013 XLS
Reference Check Worksheet 10/1/2008 Word
Final Evaluation Document 8/26/2014 XLS
Final Evaluation Document for Cafeteria and Vending Services 2/27/2014 Word
Oral Interview Letter - Version One 10/1/2008 Word
Oral Interview Letter - Version Two 10/1/2008 Word
Oral Interview Letter - Version Three 10/1/2008 Word
Oral Interview Scoring Worksheet 10/1/2008 Word
Final Evaluation Document with Oral Interviews 8/26/2014 XLS
Final Evaluation Document with Oral Interview for Cafeteria and Vending Services 2/27/2014 Word
Best and Final Offer (BAFO) Letter 9/12/2017 Word
Final Evaluation Document with Best and Final Offer (BAFO) 8/26/2014 XLS
Award Instructions Letter 2/26/2015 Word
Description Last Revised Format
Processing Timeline for Commodities/Goods 11/2/2023 Excel

ITB Boilerplate and Forms

Description Last Revised Format
Invitation to Bid (ITB) Boilerplate 5/25/2023 Word
ITB Boilerplate Changes 5/25/2023 PDF
Specification Tutorial and Introduction to ITB Boilerplates Powerpoint 9/15/2015 PDF
Printing 101: Guidelines for a Successful Print Project 4/17/2017 PDF
Solicitation Announcement Letter 4/1/2015 Word
Pre-Bid Attendance Sheet 10/16/2014 Word
Pre-Bid Conference Questions 10/1/2008 Word
Addendum - Questions and Answers 9/23/2015 Word
Addendum - Amendment to ITB 10/16/2014 Word
Addendum - Change of Scope 10/16/2014 Word
Addendum - Schedule of Events Change 10/16/2014 Word
Addendum to Contract 7/21/2015 Word
Amendment to Contract 7/21/2015 Word
Rejection of Bids 10/1/2008 Word
Request for Fax or Electronic Quote 8/25/2015 XLS
Specification Comparison Tool 12/10/2013 XLS
Non-CSI Justification Form (Form G-3) 11/30/2023 PDF
Non-CSI OW Requisition Example and Instruction 8/17/2017 PDF
Description Format
July 2023 - September 2023 PDF
April 2023 - June 2023 PDF
January 2023 - March 2023 PDF
October 2022 - December 2022 PDF
July 2022 - September 2022 PDF
April 2022 - June 2022 PDF
January 2022 - March 2022 PDF
October 2021 - December 2021 PDF
July 2021 - September 2021 PDF
April 2021 – June 2021 PDF
January 2021 - March 2021 PDF
October 2020 - December 2020 PDF
July 2020 - September 2020 PDF
April 2020 - June 2020 PDF
January 2020 - March 2020 PDF
October 2019 - December 2019 PDF
July 2019 - September 2019 PDF
April 2019 - June 2019 PDF
January 2019 - March 2019 PDF
Description Format
09/01/2023 PDF
09/01/2022 PDF
09/01/2021 PDF
09/01/2020 PDF
09/01/2019 PDF
 

 

SURPLUS PROPERTY/ASSET MANAGEMENT
Description Last Revised Format
Surplus Property Manual 11/7/2023 PDF
Surplus Property Assessment Form 11/7/2023 PDF
Surplus Photo Guidebook 11/7/2023 PDF
Asset Management Manual 2023 11/7/2023 PDF
Annual Fixed Asset/Annual Inventory Letter FY 22/23 4/17/2023 PDF
Barcode Scanner Manual 8/18/2022 PDF
SPN Form for Non-Fixed Asset 11/7/2023 Excel
AS SURPLUS ECM Instructions 6/24/2014 PDF
Surplus Property Training PowerPoint 11/7/2023 PPT

 

STATE MAIL CENTER
Description Format
Mail Services Guide PDF
Change of Address Form PDF

 

STATE PRINT SHOP AND COPY SERVICES
Description Format
Copy Center Requisition XLS

   

 

Personnel

State Personnel Systems

Employee Work Center and Workday

Career Center

Payroll & Financial Center

Other Useful Links

User Guides
Classification & Compensation
State Personnel Expedited Classification Process
Title 273, Classified Personnel Rules
Personnel Almanacs
Salary Surveys
Furlough Guide
Telecommuting Guidelines
PDQ - Position Description Questionnaire
Financial Responsibilities Questionnaire
Supervisory Questionnaire
Confidentiality Questionnaire
Labor Contract Compensation Request Form
Rules Compensation Request Form
Equity Considerations Guidance
Training and Development
Teammate Engagement
Wellness & Benefits
Section Title
1 Employee Assistance Program
2 Health & Prescriptions Plans
3 Dental
4 Vision
5 Flexible Spending Accounts
6 Health Savings Account
7 Life Insurance
8 Long & Short Term Disability

 

SOS Temporary Employee Benefits

 

Section Title
1 Health & Prescriptions Plans
2 Dental
3 Flexible Spending Accounts (Dependent Care ONLY)
4 Health Savings Account
5 Long & Short Term Disability

 

 

COBRA

 

Open Enrollment Information

 

Pay Plan

Quarterly Pay Plan Changes

Previous Classification & Pay Plans

Employees covered by Bargaining Units, visit the Bargaining Unit Pay Plans page.

 

 

To view previous pay plans, visit the State Government Publications ONLINE at the Nebraska Library Commission

Temporary Employment Program (SOS)

 

Temporary Employment Program (SOS)
Chapter 4 – Temporary Employment, Classified System Rules and Regulations
Manager Time Entry Approval
Payroll Schedule
Reimbursement Request
Daily Time Entry

Risk Management Division


Types of State Claims


TORT CLAIMS
A claim against the State of Nebraska for damage to or loss of property or for personal injury or death caused by the negligent or wrongful act or omission of a State employee while acting within the scope of employment.
Description Last Revised Format
State Tort Claims Act at Neb. Rev. Stat §§81-8,209 to 81-8,235 External
Tort/Miscellaneous Claim Form 06/28/2018 PDF
How to File a Tort Claim 05/17/2021 PDF

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MISCELLANEOUS CLAIMS
A claim against the State of Nebraska for which there is no specific provision of law for the resolution of such claim. Typically miscellaneous claims include but are not limited to: reimbursement for a State teammate’s personal property that was damaged during the course and scope of employment, or a reimbursement for overpayment of goods or services.
Description Last Revised Format
State Miscellaneous Claims Act (includes uncashed warrants): Neb. Rev. Stat. §§ 81-8,294 to 81-8,301 External
Tort/Miscellaneous Claim Form 06/28/2018 PDF
Tort/Miscellaneous Claim Form for inmates at NDCS, only 06/28/2018 PDF
How to File a Miscellaneous Claim 05/17/2021 PDF

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UNCASHED WARRANT CLAIMS
A claim to have an uncashed check/warrant reissued. These items expire one year after the date the check/warrant was issued. If a copy of the warrant is not available, an affidavit regarding the lost or missing warrant must accompany the claim form.
Description Last Revised Format
Uncashed Warrant Claim Form 06/28/2018 PDF
Affidavit Regarding Lost or Missing Warrant 03/03/2016 PDF
How to File an Uncashed Warrant Claim 05/17/2021 PDF
W9 Form External

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CONTRACT CLAIMS
A claim involving a dispute regarding a contract between the State of Nebraska and the Claimant. The Contract Claim Act does not cover employment contracts under the State Personnel System or the State Employees Collective Bargaining Act.
Description Last Revised Format
State Contract Claims Act: Neb. Rev. Stat. §§ 81-8,302 to 81-8306 External
Contract Claim Form 06/22/2018 PDF
How to File a Contract Claim 05/17/2021 PDF

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FOSTER CARE CLAIMS
A foster care claim may be filed when a foster child(ren) has been involved in an incident resulting in property damage or bodily injury to others.
Description Last Revised Format
Foster Care Claim by Foster Parent Form 09/25/2018 PDF
Foster Care Claim by Non Foster Parent Form 05/17/2022 PDF

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IN THE LINE OF DUTY CLAIMS
A claim for first responders killed in the line of duty. (Program Begins 1 January 2022).
Description Last Revised Format
In the Line of Duty Compensation Act: Neb. Rev. Stat. §§ 81-8,315 to 81-8,319 External
Line of Duty Compensation Act Beneficiary Form 12/07/2021 PDF
Line of Duty Compensation Act Claim Form 01/01/2024 PDF
How to File a Line of Duty Compensation Act Claim 01/01/2024 PDF

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CORRESPONDENCE TO STATE AGENCIES
A claim for first responders killed in the line of duty. (Program Begins 1 January 2022).
Description Last Revised Format
Debt Write-Off Procedures and Request for Write-Off for State Agencies 09/06/2022 PDF
Request for Write Off of Uncollectible Debt Form for State Agencies 09/06/2022 PDF

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State Insurance


AGENCY CERTIFICATE OF SELF-INSURANCE

If an agency needs a Certificate of Insurance specifically listing the agency's name or other information, please complete the Form to Request Certificate of Self-Insurance and email it to the address listed on the form.

Description Last Revised Format
Form to Request Certificate of Self-Insurance 07/03/2018 PDF
Certificate of Self-Insurance Instructions to Agencies 07/01/2023 PDF

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HOW TO FILE AN INSURANCE CLAIM

Instructions for Agencies on how to file a State Insurance claim.

Description Last Revised Format
How to Report Insurance Claims for State of Nebraska Agencies 08/16/2022 PDF
Incident Report Form for Claims Exceeding Deductible 06/25/2018 PDF
Driver Motor Vehicle Accident Report 10/01/2020 PDF

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AUTO INSURANCE

Information for Agencies regarding State Insurance for Automobiles.

Description Last Revised Format
State of Nebraska Motor Vehicle Policy 07/01/2023 PDF
State of Nebraska Automobile Insurance Card 05/31/2023 PDF
State of Nebraska State Vehicle Waiver 02/01/2022 PDF
TSB Leased Vehicle Accident Insurance Claim Procedure 06/28/2021 PDF

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ANNUAL INSURANCE POLICY LETTERS

Annual information for Agencies for State Insurance.

Description Last Revised Format
Current Building Replacement Rates for Insurance 01/06/2022 PDF
State of Nebraska Annual Insurance Renewal for Current Fiscal Year 01/22/2022 PDF

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STATE OF NEBRASKA INSURANCE POLICIES

Policies related to State of Nebraska Insurance.

Description Last Revised Format
State of Nebraska Contract Risk Management and Insurance Manual 02/28/2020 PDF
State of Nebraska Bonding with Crime Insurance Policies 07/01/2022 PDF

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Statewide Safety Committee


SAFETY COMMITTEE CHARTER AND MEMBERSHIP

The Workers’ Compensation reform Act of 1993 (LB 757) required all employers, including the state of Nebraska, to create safety committees. The Act stipulated that each committee would be created with equal representation from labor and management. The committee established by the state to meet this requirement is called the Statewide Safety Committee.

The committee adopted its mission statement; “To promote a safe and healthy work environment for all Nebraska state employees.”
Description Last Revised Format
State of Nebraska Safety Committee Charter 04/27/2016 PDF
State of Nebraska Safety Committee Basic Program Guidelines 11/28/2016 PDF
State of Nebraska Safety Committee Membership 11/29/2022 PDF

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REPORT UNSAFE CONDITIONS TO THE STATEWIDE SAFETY COMMITTEE

The Statewide Safety Committee is here to support all state employees. If you have a concern about safety, please use this form to report unsafe conditions to the Safety Committee.

Description Last Revised Format
Report Unsafe Conditions to the Safety Committee 05/24/2017 PDF

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STATEWIDE SAFETY COMMITTEE MINUTES

Minutes from the Statewide Safety Committee Meetings.

Description Last Revised Format
2023 Safety Committee Minutes
May 2023 Safety Committee Minutes 05/23/2023 PDF
March 2023 Safety Committee Minutes 03/28/2023 PDF
January 2023 Safety Committee Minutes 01/31/2023 PDF
2022 Safety Committee Minutes
November 2022 Safety Committee Minutes 11/29/2022 PDF
September 2022 Safety Committee Minutes 09/28/2022 PDF
July 2022 Safety Committee Minutes 07/26/2022 PDF
May 2022 Safety Committee Minutes 05/24/2022 PDF
March 2022 Safety Committee Minutes 03/29/2022 PDF
January 2022 Safety Committee Minutes 01/24/2022 PDF
2021 Safety Committee Minutes
November 2021 Safety Committee Minutes 11/30/2021 PDF
September 2021 Safety Committee Minutes 09/28/2021 PDF
July 2021 Safety Committee Minutes 07/27/2021 PDF
May 2021 Safety Committee Minutes 05/25/2021 PDF
March 2021 Safety Committee Minutes 03/23/2021 PDF
January 2021 Safety Committee Minutes 01/19/2021 PDF
2020 Safety Committee Minutes
January 2020 Safety Committee Minutes 01/21/2023 PDF

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Types of Workers' Compensation Information


WORKERS' COMPENSATION TRAINING INFORMATION

The workers’ compensation program for State of Nebraska employees is administered by the Department of Administrative Services, Risk Management Division.

Description Last Revised Format
Workers' Compensation Policy and Procedure Manual 07/14/2022 PDF
Workers' Compensation Policy and Procedure Video 07/14/2022 PDF

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REPORTING INJURY - INITIAL COMPLETION OF FORMS

When an injury occurs, it should be reported immediately to the employee’s supervisor or Agency HR. The injured employee must complete the following forms and turn them in to Agency HR:

  • Employee Incident Report;
  • Authorization for Release of Information (HIPAA Compliant); and
  • Employee’s Choice or Change of Doctor Form (Form 50).

Supervisors shall complete and submit to agency human resources representative:

  • Supervisor Investigation Report and;
  • Witness Form.
Description Last Revised Format
Employee Incident Report 02/16/2018 PDF
Authorization for Release of Information (HIPAA Compliant) 02/16/2018 PDF
Employee’s Choice or Change of Doctor Form (Form 50) 03/01/2018 PDF
Supervisor Investigation Report 02/16/2018 PDF
Witness Statement (Supervisor should have all individuals who witness the injury complete this form.) 02/16/2018 PDF

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AGENCY HR - DIRECTIVES TO THE INJURED EMPLOYEE

Medical Treatment Needed:

Agency HR should provide the injured employee with the following forms and information:

  • 7 Day Wait Period Acknowledgment Form;
  • Request to Supplement Workers’ Compensation Benefits Form;
  • Report of Work Ability;
  • myMatrixx First Fill Form (Replaces First Script Pharmacy Card);
  • Mileage Reimbursement Form;
  • Pamphlet on GBGO App.

Medical Treatment NOT Needed:

Agency HR should provide the injured employee with the following forms and information:

  • 7 Day Wait Period Acknowledgment Form;
  • Request to Supplement Workers’ Compensation Benefits Form;
  • Pamphlet on GBGO App.
Description Last Revised Format
7 Day Wait Period Acknowledgment Form 02/16/2018 PDF
Request to Supplement Workers’ Compensation Benefits Form 02/16/2018 PDF
Report of Work Ability 09/16/2022 PDF
myMatrixx First Fill Form (Replaces First Script Pharmacy Card) 02/16/2018 PDF
Mileage Reimbursement Form 02/16/2018 PDF
Pamphlet on GBGO App 02/16/2018 PDF

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AGENCY HR - AFTER CLAIM HAS BEEN FILED

After the claim has been filed, Agency HR should complete and submit the following forms to the assigned Resolution Manager on the newly filed workers’ compensation claim:

Description Last Revised Format
Wage Statement 02/16/2018 PDF
Payroll Benefit Analysis - Biweekly 02/16/2018 PDF
Payroll Benefit Analysis - Monthly 02/16/2018 PDF

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U.S. BANK RELIACARD INFORMATION

ReliaCard: A reloadable prepaid debit card for government agencies to deliver timely workers' compensation payments.

Description Last Revised Format
U.S. Bank ReliaCard Flyer PDF
U.S. Bank ReliaCard Pre-Acquisition Disclosure PDF
U.S. Bank ReliaCard Frequently Asked Questions PDF

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309 Task Force

309 Task Form Forms
Allocation Request Form
Allocation Increase Request Form
Final Report Form
Roof Scan Request Form

Transportation Services Bureau

TSB Forms
Form J
To be completed and returned to TSB when your agency requests a new permanently assigned TSB lease vehicle – OR – for a change in vehicle type/upgrade of designated TSB lease vehicles. Please note – changes in vehicle type/upgrades are reviewed ONLY during TSB’s annual vehicle replacement cycle. Form J instructions may be accessed here. Completion of Form J does not guarantee an upgrade and/or change in vehicle type.
Form S
To be completed and returned to TSB when your agency anticipates the need for additional vehicles on a temporary basis. Requests for seasonal or summer use vehicles will be reviewed and approved based on existing fleet availability. New vehicles will not be purchased solely to fill seasonal or summer requests.
Transportation Requests
To be completed and presented to TSB staff when renting a TSB Motor Pool vehicle. The Transportation Request is exempt if your agency has a Universal Travel Authorizations form (below) on file with TSB.
Universal Travel Authorizations
Utilized by your agency in lieu of the Transportation Requests form (above).
Official TSB Travel Logs
To be completed per Statute 81-1025.
If you are unable to access or open the Transportation Services Bureau (TSB) forms, please contact (402) 471-2897 or (402) 471-2898 for assistance.