Staff Tuition for Education Program (STEP) Application
Please read the program guidelines prior to completing this application.
Incomplete applications not containing original receipts and evidence of completion will be returned.
PERSONAL INFORMATION
First Name
MI
Last Name
Are you known by a different name at your educational institution?
If yes, what name?
PPS ID No.
Yes
No
Title
Department Name
Permanent/Home Mailing Address
Street
Is this a new address?
Yes
City
No
State
Zip
Note: Reimbursements are mailed to the address on file with Payroll.
Work Address
Building Name
Suite/ Room No.
Contact Information
Work Phone Number
Personal Phone Number
Preferred E-mail Address
EMPLOYMENT INFORMATION
Length of service with UCDHS
Years
Months
Are you are career employee?
Yes
No
Are you currently on a leave of absence?
Yes
No
If yes, please specify type of leave:
If yes, what is your expected return to work date? (MM/DD/YY)
Note: Special conditions may apply to employees on leave.
Have you had any corrective action in the last 2 years:
Yes
No
If yes, please explain:
Training & Development STEP Application
Page 1 of 5
Rev2014.0305
Staff Tuition for Education Program (STEP) Application
EDUCATIONAL INFORMATION
I am currently pursuing one of the following:
An accredited matriculated (degree-seeking) program
An accredited health sciences vocational program
Prerequisite courses towards a matriculated program
Name of Educational Institution
Name of Degree/Vocational Program
Program Type (AA, BA, etc.)
Program Began (MM/YY)
Anticipated Completion (MM/YY)
STATEMENT OF PURPOSE
Please state how this training will aid you in accomplishing your career goals at UC Davis Health System:
CAREER DEVELOPMENT PLAN
All coursework for which reimbursement is sought must support the employee's stated career objectives.
A new Career Development Plan must be filed if there is a change of degree program and/or career objective.
Please list your educational background, most recent degree listed first.
Educational Institution
Degree
Major
Year Attained
Career Objectives
What is your long-range career objective with UCDHS?
Training & Development STEP Application
Page 2 of 5
Rev2014.0305
Staff Tuition for Education Program (STEP) Application
What, if any, intervening positions will you need to obtain in order to reach your final objective?
Describe how this degree or course of study will assist in accomplishing your long-range career objective.
Please list the classes you intend to complete as part of your matriculated degree/vocational program.
You may attach a copy of the degree/vocational program or additional sheets as needed.
Course Title
Units
Quarter/Semester
Year
Cost
Estimated Total Cost of Program $
Training & Development STEP Application
Page 3 of 5
Rev2014.0305
Staff Tuition for Education Program (STEP) Application
FUNDING INFORMATION
Are you currently participating in a University reduced/discounted tuition program?
Did you receive grant or scholarship funding that was used to pay for this training?
Are you receiving other funding for the specified training?
If yes, please specify:
Yes
Yes
Yes
No
No
No
Today’s Requested Reimbursement
Please specify reimbursement type (tuition, books). See guidelines for eligible expense categories.
Date of Expense
Reimbursement Type
Amount
Total Amount Requesting $
EMPLOYEE CHECKLIST
Please check the boxes and sign to acknowledge understanding of the STEP Program.
I have read the program guidelines and understand that failure to comply could result in a reimbursement
delay, denial of reimbursement, or a reimbursement repayment to UCDHS.
I have attached the following with this application in the specified format noted in the program guidelines
 Original itemized receipts indicating amount paid and form of payment
 Proof of passing quarterly/semester grades
I understand it may take 4 – 6 weeks to receive reimbursement.
I understand if I am to separate/terminate as a career employee from UCDHS or have an appointment
change to an ineligible appointment type prior to completion of any pending funding process, I am no longer
eligible for reimbursement. Pending requests will be immediately voided.
I understand employees are responsible for any tax liability resulting from employer provided tuition
assistance. The University is required by law to report to the Internal Revenue Service the amount of tuition
assistance received that is subject to taxes.
I acknowledge the Career Development Plan serves as a tool to guide me in achieving my career objectives,
and does not guarantee promotion or any other career advancement as a result of completion of this plan.
I certify the information provided on this application is true and complete.
Employee Signature
Training & Development STEP Application
Date
Page 4 of 5
Rev2014.0305
Staff Tuition for Education Program (STEP) Application
TO BE COMPLETED BY EMPLOYEE’S SUPERVISOR
UCDHS Supervisor’s Name (Please Print)
Supervisor’s Phone Number
Career employee
Probation complete
Corrective action within last 2 years
Satisfactory performance appraisal
Employee’s performance
Email Address
Yes
No
Yes
No
Yes
No
Yes
No
Exceeds expectations
Meets expectations
I certify this information is true and complete.
UCDHS Supervisor’s Signature
Date
SUBMISSION GUIDELINES
Please read the program guidelines prior to completing this application. Incomplete applications not
containing original receipts and evidence of completion will be returned. All documents and receipts should
be hand-delivered or sent via inter-office/U.S. mail to the Human Resources Training & Development Unit at
the following address:
UCDHS Human Resources
Training & Development, Room 2600
2730 Stockton Blvd. Ticon III Bldg.,
Sacramento, CA 95817
TO BE COMPLETED BY TRAINING AND DEVELOPMENT
Training and Development Reviewer
Training & Development STEP Application
Date
Page 5 of 5
Rev2014.0305