PERSONNEL CHANGE FORM
Effective Date of Action: Employee First Name: Resignation / Termination: Reason: Last Day Worked: End date: Last Name: Employee ID: Faculty
Vacation Days Due:
Leave of Absence: (Faculty leaves require Provost approval) Type of Leave: Medical Military Benefit/Coverage: W/Out Pay, W/ Benefits W/ Part Pay, W/ Benefits
(check all that apply and complete applicable fields)
Personal Other: W/Out Pay, W/Out Benefits W/ Pay, W/ Benefits Grants / Research Ext.: Staff Temporary Other:
Date of Return:
Transfer
Promotion / Reclassification
Salary Change New Org #: Room: Faculty Part-Time
Transfer:
New Department Name: Campus Location: Building: New Title: Status: Administrator Type: Full-Time
Promotion/ Reclassification: Salary/Rate Change:
(check all that apply)
Public Safety Reduced Schedule
New Hourly Rate: # hours per pay: New Annual Salary: Special Earnings / Stipend: # Of Pays: Secondary Job: # Of Pays: New Continuing End Date: Dept. Name:
End Date: End Date:
Grant / Research: Special Instructions:
FUND
ORG
ACCOUNT
% DIST. 100%
AMOUNT
END DATE
# OF – PAYS
COMMENTS
Special Hire:
Regular Student Org #: Building:
Work Study
Grad. Asst.
Temp/Per Diem Other:
Department Name: Campus Location: Job Title: Comments:
Dean / Budget Admin:
Hourly Rate / Salary:
# hours per pay:
APPROVED BY:
Provost Office (academic units only):
Date: Date:
APPROVED BY:
E-MAIL - Human Resources
SJU PCF 8/2006