Human Resources Forms
Authorized Driver Request Form
Benefit Forms
- Benefit-related forms can be found on the Benefits page under the appropriate benefit name.
Disability and Reasonable Accommodation Form
Injury/Illness Reporting Forms
- Reporting Injuries
- Occupational Clinic Poster
- Concentra West Inland Empire Locations
- Employees Report of Injury Form
- Supervisors Report of Injury Form
- Worker’s Compensation Packet
Payroll Forms
- Makeup Time Request (PDF)
- Meal Period Waiver Agreement – English
- Meal Period Waiver Agreement – Español
- Meal Period Exception Log – English
- Meal Period Exception Log – Español
- HMC Timekeeping Exception Log – English
- HMC Timekeeping Exception Log – Español
Rideshare Forms
Staff Handbook Acknowledgement Form
Tax Withholding Forms
HR Forms Contacts
Please contact any member of the HR team for questions related to HR forms.
Dana Nagengast, SHRM-SCP
Assistant Vice President – Chief Human Resources Officer (AVP-CHRO)
909.621.8512
dnagengast@xjiu.net
Patrice Siffert, SHRM-SCP
Associate Director for Human Resources
909.607.4154
psiffert@xjiu.net
Catharyne Magro
Human Resources Coordinator
909.607.9700
cmagro@xjiu.net
Nidia Rivera
Recruiter & HR Generalist
909.607.4096
nirivera@xjiu.net
José Barajas
HR Analyst & Administrator
909.607.6531
jbarajas@xjiu.net
Haley Phillips
Assistant Director for Special Projects (part-time)
909.607.4096
hphillips@xjiu.net