Benefits

Forms

• Affidavit for Domestic Partner
• Affidavit of Marriage
• Blue Shield Authorization
• Donation of Vacation Hours Form
• Evidence of Insurability - Anthem
• Health Equity Health Savings Account Transfer Form
• Health Insurance Waiver
• KAISER AUTHORIZATION/DISCLOSURE
• Life Insurance Beneficiary Form
• Request for Leave Form
• Salary Reduction Agreement 
• Transit - Election and Change

Retirement Plans

• 401a SPD
• 403b SPD
• Fee Disclosure Notice 2016

California Voluntary Disability

• 2017 SCU - CVP Employee Memorandum
• 2017 SCU - CVP Plan Document
• 2019 SCU - CVP Statement of Coverage

Delta Dental

• Delta Dental Benefit Summary
• Delta Dental PPO Contract

CBIZ

• CBIZ FSA Information
• CBIZ Consumer Portal QuickStart Guide
• CBIZ Dependent Care Account Information
• CBIZ SCU Transit Plan Election and Change Form
• CBIZ Transit FSA Overview
• CBIZ FSA How to File a Claim
• CBIZ FSA Claim Form
• CBIZ Medical Flexible Spending Account FAQ's
• CBIZ Take Care Debit Card
• CBIZ Take Care Debit Card FAQ's

 Blue Shield

• Blue Shield Access+ Evidence of Coverage
• Blue Shield PPO Evidence of Coverage
• Blue Shield Trio HMO Evidence of Coverage
• Blue Shield Summary of Benefits HMO Trio
• Blue Shield Summary of Benefits HMO Trio Spanish
• Blue Shield Summary of Benefits Custom Access+HMO
• Blue Shield Summary of Benefits Custom Access+ HMO Spanish
• Blue Shield Summary of Benefits PPO
• Blue Shield Summary of Benefits PPO Spanish
• Blue Shield How to find a Doctor Steps
• Blue Shield Comparison HMO Networks BA & Central CA Counties
• Blue Shield RX 90-Day Transition Program
• Blue Shield Away from Home Brochure
• Blue Shield Away From Home Care Map
• Blue Shield Away from Home Care Application
• Blue Shield Continuity of Care Program
• Blue Shield Continuity of Care Application

Kaiser

• Kaiser Evidence of Coverage
• Kaiser Summary of Benefits HMO
• Kaiser Principal Benefits HMO

Health Equity (HSA)

• Health Equity Web Link

ACA, IRS Form 1095-C

• 1095-C Information
• 1095-C Information (Spanish)
• 1094-C and 1095-C Forms Guidance

Benefit Enrollment Notices

• Health Insurance Memorandum
• CHIP Notice
• Medicare Part D

SCU offers its employees multiple leave options.

The University provides leaves of absence to enable employees to attend to personal and professional obligations, and for periods of disability. All requests for leaves should be submitted to the Department of Human Resources for processing and approval. Managers should direct any employee requests for leave to Benefits in the Department of Human Resources.

For detailed information, employees can consult the Staff Policy Manual for each type of leave below:

• General
• Sick
• Family and Medical
• Personal
• Pregnancy Disability
• Bereavement
• Civic
• Military
• Emergency

Need to File an FMLA/ PFL / STD / LTD Claim?

In an effort to improve the processing time and simplify the claims experience for employees, Santa Clara University has contracted with Matrix Absence Management (Matrix), a division of Reliance Standard Life Insurance Company, to administer the Short Term Disability (STD)/Paid Family Leave, Long Term Disability (LTD) and Family Medical Leave Act (FMLA) programs.

Read the Matrix Leave of Absence Brochure.

See Also

• Family Rights & Responsibilities under the Family and Medical Leave Act - revised 2/2013(PDF 260KB)
• Staff Paternal Leave Timeline
• Staff Maternity Leave Timeline
• Leave of Absence Guides and Forms
  • Staff Leave of Absence Guide
  • Kaiser HIPAA Authorization
  • Request for Leave Form
• Statement of Coverage Voluntary Plan

Refer the employee to Benefits in the Department of Human Resources. Notify the Benefits office of the request. Provide the name of the employee and the nature of the request.

ADA Employee Accommodation Request Form

ADA Healthcare Provider Form

ADA Packet Healthcare Provider Authorization Release

Lactation Accommodations

Employees can coordinate lactaction accommodations directly with their supervisor and any questions can be directed to Indu Ahluwalia. 

Requirements for Lactation Accommodation

Provide Break Time to Express Breastmilk.

• Managers are required to provide a reasonable amount of break time to accommodate an employee desiring to express breastmilk for the employee's infant child. If possible, the break time should coincide with the employee's paid break time. If not, the break time need not be paid. 

Provide the Employee with the Use of a Room to Express Breastmilk.

• The manager and employee should work together to identify a room or other location for the employee to express breastmilk if the employee does not have their own office. This space should be private and in relatively close proximity to the employee's work area. This space cannot be a toilet stall. 

Examples of workplace spaces used for expressing breastmilk:

• An employee's own office.
• A vacant room which can be arranged to be used by lactating employee during specific times of the day. 
• Private Wellness Room (see University map below).
• A conference room they can reserve.

A room can be made private by having a lock on the door, placing a message on the door that the room is in use, drawing blinds or curtains, covering curtainless windows, or setting up a portable partition. 

The following items would be helpful to have in the space, but not required.

• A clean, safe water source, sink, disinfectant dish soap, and paper towels nearby for washing hands and breast pump equipment. 
• A refrigerator or ice chest to keep breastmilk from spoiling. 
• A room with an electrical outlet for employees who use an electric breast pump to express milk. 
• A comfortable chair to sit in while expressing milk. 
• A small table for pumping supplies. 

Any questions regarding these requirements can be addressed to Indu Ahluwalia, Sr. Leave Specialist at x5750 or iahluwalia@scu.edu.

Wellness Rooms

SCU provides wellness rooms throughout the university campus in various locations. These wellness rooms can be used as Lactation rooms on campus. Please see the attached University map for the current locations and future locations that SCU plans to add to enhance the overall program. Employees can coordinate lactaction accommodations directly with their supervisor. 

 Campus Wellness Rooms Map

Questions regarding leaves processing for workplace injuries and Illnesses:

If you, or someone who reports to you, suffer a work-related injury or illness, the following steps should be taken immediately:

Is the injury a life threatening emergency? 

Yes: If the injury is life threatening, contact SCU Campus Safety (408) 554-4444 or 911 and arrange for an ambulance. Notify the employee's supervisor and the Department of Human Resources (408) 554-4392.

No: If the injury is not life threatening, employees must notify their supervisors and contact the Department of Human Resources (408) 554-4392. The Department of Human Resources will authorize treatment at U.S. Healthworks.

If the injury occurs outside of normal office hours, employees must call the Department of Human Resources and leave a message and then obtain medical care from the O'Connor Hospital Emergency Room

If the Injury Does Not Require Immediate Medical Treatment

If medical or other emergency care is not needed for the injury, employees must notify their supervisors and the Department of Human Resources (408) 554-4392.

The Following Applies to All Injuries

All work-related injuries and illnesses

The Department of Human Resources will provide employees with:

1. Employee Incident Report Form(PDF 713KB)
2. Workers Comp DWC Form(PDF 147KB)
3. US Healthworks Authorization Form(PDF 65KB)

Employees are required to complete the report and forms as soon as possible.

Following receipt of initial medical treatment

1. Give a copy of the “work status report” to your supervisor.
2. Review “work status report” with your supervisor to evaluate any job limitations and/or modifications directed by the physician.

If you need follow up care, please remember the following:

1. University practice is to pay employees regular time for time missed from work not only for the initial receipt of care, but for follow up care as well.
2. Physical therapy appointments must be pre-arranged with supervisor. Time missed for travel to and from and duration of appointment is paid at regular time.
3. Keep your supervisor apprised of any changes to your work status.

If your injury or illness requires a temporary period of time away from work?

1. Immediately notify your supervisor and the Department of Human Resources (408) 554-4932.
2. Complete the appropriate paperwork for an industrial leave of absence
3. Communicate regularly with the Worker’s Compensation insurance provider regarding your treatment, care, and work status.

*Please contact the Department of Human Resources with any questions at (408) 554-4932.

See Also

• US HealthWorks Clinics
• Concierge Claim Nurse
• US HealthWorks Authorization Form
• US HealthWorks Pharmacy Locations
• US Healthworks - San Jose, CA - Driving Directions
• O'Connor Hospital - Driving Directions
• Refusal of Medical Treatment or Observation
• Authorization to Treat (Alliance)(PDF 1.2MB)
• Medical Provider Network
• Worker's Compensation Benefits
• Worker's Compensation Benefits(Spanish)

Contact the appropriate office as soon as possible. (Campus Safety, Employee Relations, Title IX, Benefits office.)

If you are not sure who to contact call the Department of Human Resources for assistance.

Santa Clara University offers a program of employee benefits designed to enhance the well-being of its employees. In compliance with Federal and State laws, the University provides the following statutory benefits to all of its eligible employees, as defined by Federal and State law.

Social Security

Most employees participate in the Social Security Program through a mandatory payroll deduction. Social Security provides a retirement benefit for individuals who have worked the number of years required for eligibility. Other benefits may include disability income, survivor, dependent, and medical benefits. The amount contributed, which is matched by the University, is based on rates determined and established by the Social Security Administration.

Worker’s Compensation

The University provides a no-fault Worker’s Compensation insurance program. If an employee is unable to work because of on-the-job injury or illness, Worker’s Compensation covers medical expenses and pays a portion of lost wages based on the nature of the injury.

Unemployment Insurance

Most employees of the University are covered by the State Employment Security Law. Under the provisions of this law, employees of the University who become totally or partially unemployed, and who meet the eligibility requirements as set forth in the law, may be eligible to receive unemployment compensation.

EAP provides professional counseling, information, and referral services to faculty, staff and their families. The program offers confidential consultation on a wide variety of personal, family and/or work-related problems that may contribute to high levels of stress and interfere with health and work performance.

EAP is a great service designed to help with the following:

• Stress
• Family or Parenting issues
• Alcohol or drug dependencies
• Adjusting to change
• Self-improvement
• Child and elder care
• Pre and postnatal concerns
• Grief
• Work/life balance
• Legal and financial consultation services