Personnel Action Form - DOC by HC120705065047

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									                                           Personnel Action Form
Employee Name:                                                      Title:

Dept:                                                       SSN#:

COMPENSATION CHANGE Effective Date:
Reason (Check One): Merit         Promotion/Transfer                Salary Adjust.  Other
Current Amount: $               Pay Type: Base Rate                  Base Rate Type:             Hourly
                                            Bonus                                                Salary

New Amount:      $                          Pay Type:   Base Rate     Base Rate Type:            Hourly
                                                        Bonus                                    Salary
Attachments:         Compensation/Performance Review                 Other:
JOB CLASSIFICATION CHANGE Effective Date:
Reason (Check One):  Promotion    Result of Evaluation Lateral Change                    Other
Current Job Title:                                    Exempt Status:                      Exempt
                                                                                          Non-Exempt
New Job Title:                                                  Exempt Status:            Exempt
                                                                                          Non-Exempt
WORK STATUS CHANGE Effective Date:
Reason (Check One):           Employee Requested                    Department Restructure
New Work Status (Check One): FT Regular      PT Regular             FT Temp       PT Temp
Scheduled Work Days:         M      TU      W     TH                F     SA      SU
Scheduled Hours Per Week:    40     Less Than 30

LEAVE OF ABSENCE (LOA) STATUS CHANGE Effective Date:
LOA REASON (Check One):                    Personal   Medical      Maternity      Work Comp
Doctor's Note Attached? (Check One):       Yes         No
Estimated Return Date:                     Doctor's Release Received for Return to Work? Yes              No
PERSONAL INFORMATION CHANGE Effective Date:
Change in Marital Status: Married Single

New Last Name:                                     New First Name:

New Street Address:                                                 City                 ST    Zip

Home Phone(           )                    Mobile (     )           Pager (          )

Emergency Contact                                                   Phone



Employee Signature                                                            Date


Supervisor Signature                                                          Date

								
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