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REVISEDPAF by liamei12345


									                                                                                                                                Mark box – Route to:
                                                                                                                                  HRS           Employee                        Budget
                                                                                                                                  Payroll       Division                        Office

                                                                              PERSONNEL ACTION FORM
Complete form if hiring fulltime classified staff, part-time hourly, and student employment positions. Do not use this form for
hiring full-time faculty and administrative positions. Complete form for rehire, budget code change, volunteer, separation, and
supervisor change.

SECTION 1 – PERSONAL INFORMATION                                    OC System ID #                       New Hires: Last 4 digits of SSN:

Employee Name: Last                                                 First                                                                    MI
Action: Choose an item.

Type of Staff or Student Position: Choose an item.

Job Title/Classification:
(All positions including State Work Study must complete Job Title. Leave blank for RSE, Federal Work Study and Work First Work Study)

New Position:                   Yes           No Person Replaced:                       (If no, must complete except for student position.)

Start Date:                                   Supervisor:                                                                Dept. Phone Number:

End Date:                                     Department/Location:                                                       Contact Person:


Account Code(s):
                                   APPROP. PROG. INDEX SUB OBJ. POS. NO

Budget Administrator Signature or Supervisor Signature ID                                                                                    Date

SECTION 3 -- SEPARATION INFORMATION                                              Last Date Worked:
1) How Notified:   Verbal          Written           Other
2) Have you given employee notice that they will return (reasonable assurance)?    Yes                                                No
3) Reason For Separation:   Voluntary                Discharged              Lack of work                                                         Temporary
     3.A) Explain:

4) All college property (employee ID, name tag, business card, keys, books, etc,) returned?                                          Yes          N/A                No
    4.A) If no, what property not returned:

Supervisor Signature or Supervisor Signature ID                                                                                              Date

FOR HUMAN RESOURCE ONLY:                         APP        W-4         I-9       Retirement     Waiver            Direct Deposit     BK/Ground Check              Minor         Other
Funding:                                                                      Position Control Number:
Cyclic:     Yes        No         (Months)                               %FTE
Action Code:                             Job Class:                           Range:                         Step:                                    Job#
Previous Jobs:                                            Dept. Code:                                    Salary:                                  Per Hour            Per Month
Position Previously Eligible:           Yes      No           Subject to Civil Service Rules         Yes            No          Insurance Eligible:          Yes           No
Shift Differential      Yes        No            Retirement Plan:        Yes           No                                      Separation Code:         ______________________

                                        Human Resource director/designee signature                                                         Date

Revised: 05/19/2010

Action: Choose an item.

Type of Staff or Student Position: Choose an item.

These are drop down boxes. Please click in the “Choose an item” box to view the arrow for the options.
Click arrow and choose corresponding option.

New Hires
New student hires and new staff hires must visit Human Resource
Services to complete hiring forms, such as I-9, W-4, etc., before the
start of employment date. Please advise new hire to bring documents
to satisfy the I-9 form.

Contact Person
This may be the person who completes this form.

Budget Code
Must be completed before submitting to HRS.

Supervisor Signature ID Number
Call HRS, ext. 7300 for your supervisor signature ID number.

Supervisor may check the status of new employees by visiting the HR
Share point website

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