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CSULB RESEARCH FOUNDATION
EMPLOYMENT STATUS FORM – NOTICE TO EMPLOYEE
This form must be completed for all changes in job classification, salary rate and/or job status. Form must be received by Foundation
HR 5 working days prior to the employee’s start/change date. Changes are not valid/approved until signed off by Foundation HR.
Questions? (562) 985-7485.
** NEW REQUIREMENT FOR HOURLY (NON-EXEMPT) EMPLOYEES **
Effective January 1, 2012 CA Labor Code Section 2810.5(a) requires certain information contained in this form be provided to each
employee at the time of hire and within 7 days of changes (not routine re-hires where nothing has changed). Please complete the
form, sign on reverse side (2nd page), have employee sign and provide them with a copy for their records prior to sending to college
for signature.
EMPLOYEE INFORMATION:
EMPLOYEE NAME: CSULB ID#:
DEPT/PROJECT NAME: EMPLOYEE PHONE EXT.
TYPE OF TRANSACTION – Check all that apply:
New Hire Re-Hire Change
REQUIRED – Current CSULB Employee? Yes No If Yes, Dept?
CSULB Work Schedule (Days/Hrs):
EMPLOYMENT INFORMATION:
Employment is “at-will” and can be terminated at any time, with or without cause or advance notice by either the employer or employee.
Job Classification: Working Title:
START DATE: END DATE:
*If project start/end dates vary by project – attach separate sheet as addendum indicating project # and
corresponding start/end date(s). Project period (start/end date) is simply a budget period and is not a guarantee of
employment for any specific amount of time.
FOUNDATION WORK SCHEDULE (Days/Hrs):
EMPLOYMENT AGREEMENT: Oral Written (Attach copy, benefitted employees receive offer letter from HR).
WORKING WITH MINORS OR ELDERLY? Yes No If yes, fingerprinting clearance required prior to work.
STATUS:
Benefitted Categories (Requires Position Posting): Non-Benefitted Categories:
Full-Time (30-40 Hrs) hours per week Undergraduate Student * hrs/week (max 20)
Part-Time (20-29 Hrs) hours per week Graduate Student * hrs/week (max 20)
Temporary */** hours per week
Benefitted Position #: Will Temporary Employee Need E-mail? Yes No
All benefitted positions must be posted on the Foundation website *Attach scope of work/job description.
for a minimum of 2 weeks. Contact HR for assistance. ** Max. 6 month appointment.
SALARY INFORMATION:
OPTION 1 OPTION 2
HOURLY (Non-Exempt) EXEMPT (Salaried – Requires prior HR approval)
Regular Rate Per Hour: $ Salary Per Pay Period (24 x Year) $
(Annual Salary divided by 24)
Overtime Pay Rate $ (1.5 x Reg. Rate) Effort %: Annual Wage: $
(Time worked over 8 hrs/day or 40/hrs per week; Sat through Fri) (Salary per pay period x 24)
1 Project#: GL#: 1 Project#: GL#: Effort%:
2 Project#: GL#: 2 Project#: GL#: Effort%:
3 Project#: GL#: 3 Project#: GL#: Effort%:
4 Project#: GL#: 4 Project#: GL#: Effort%:
5 Project#: GL#: 5 Project#: GL#: Effort%:
Total = 100%
Employment Status Form/Notice to Employee – 3/2012 Page 1 of 2
NOTICE TO EMPLOYEE
EMPLOYER INFORMATION
Employer Name: CALIFORNA STATE UNIVERSITY, LONG BEACH RESEARCH FOUNDATION
A.K.A.: CSULB Foundation, CSULB Research Foundation, Foundation
Employer Address: 6300 State University Drive, Suite 332, Long Beach, CA 90815
Employer Phone #: 562-985-5537
Employer Website: http://www.foundation.csulb.edu
Type of Employer: Corporation
PAY INFORMATION
Pay Schedule: Semi-monthly*
Pay Date: Typically 10 days following the end of the pay period – see pay schedule for exact date
Link to Pay Schedule: http://www.foundation.csulb.edu/forms/#Payroll
*Timecards must be turned in according to the CSULB Research Foundation pay schedule each pay period.
WORKER’S COMPENSATION INFORMATION
Insurance Carrier: Sedgwick CMS
Carrier Address: PO Box 14479, Lexington, KY 40512
Carrier Phone #: 916-851-8000 or 866-766-1115
Policy #: AO-CSURMA-09
EMPLOYEE ACKNOWLEDGEMENT RECEIPT
** ONLY REQUIRED FOR HOURLY (NON-EXEMPT) STAFF – PROVIDE COPY TO EMPLOYEE**
Employer Representative (Print Name) Hourly (Non-Exempt) Employee (Print Name)
Employer Representative (Signature) Date* Hourly (Non-Exempt) Employee (Signature) Date**
* Date provided to employee and signed by representative. ** Date received by employee and signed by employee.
Labor Code section 2810.5(b) requires that the employer notify employees in writing of any changes to the
information set forth within 7 calendar days after the time of changes, unless one of the following applies: (a) all
changes are reflected on a timely wage statement furnished in accordance with Labor Code section 226; (b)
notice of all changes is provided in another writing required by the law within 7 days of the changes. The full text
of Labor Code section 2810.5 may be found at http://www.leginfo.ca.gov/calaw.html.
The employee’s signature on this notice constitutes acknowledgement of receipt. It is the employer’s obligation
to ensure that the employment and wage-related information provided on this notice is accurate and complete.
Furthermore, the employee’s signature does not constitute a voluntary written agreement as required under the
law between the employer and the employee. Any such voluntary written agreement must be evidenced by a
separate document. The CSULB Research Foundation is an at-will employer. Employment can be terminated at
any time, with or without cause or advance notice by either the employer or the employee.
APPROVAL SIGNATURES:
Project Director (Print Name) Date Project Director (Signature) Date
College (Print Name) Date College (Signature) Date
/ / /
Grants Allowabilty Human Resources Received Date Benefit Date Processed Date
FOR FOUNDATION USE: W4 /DD
Employment Status Form/Notice to Employee – 3/2012 Page 2 of 2
