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Personnel Status Change Form (Per 3) - Instructions for Completion
There are three different files that can be used in completing a Per 3 form. The file labeled
Per 3 (salary) should be used for all full time (100% FTE) salaried employees. The file
labeled Per 3 (hourly) should be used for all full time (100% FTE) hourly employees. The
file labeled Per 3 may be used for any purpose such as terminating a student worker. Within
each file, there are 10 tabs. The tabs labeled Original, Personnel , Sponsored Proj. , and
Dept. are the first set of forms. This is the blank version in which the end user will have to
manually input all of the required fields for routing. The tab labeled Datasheet is to be used
for pasting query results to link to the next set of forms labeled Original (query), Personnel
(query),Dept. (query), Sponsored Proj. (query), and Dean-Dir Query (see Figure 1).
Figure 1
Blank set of forms (no Datasheet -for Set of forms for use with
linking data from
query) query query
Social Security # - 123-45-6789 The Social Security Number is nine (9) digits long and should be
filled out with dashes between the 3rd & 4th and 5th & 6th digits. (This may be completed without the
dashes if the query is used).
Emp. ID - Seven (7) digit employee ID number assigned from PeopleSoft.
PCN - Ten (10) digits position control number assigned to the position when it was established.
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PS Pos. - Eight (8) digits position number assigned by PeopleSoft.
Name - Jones III John H.
Last First M.I.
Names should be shown exactly as in the above example; Last Name First Name Middle Initial
Title - Assistant Professor
Title should be the official University title - should there be any question, please consult the Office of
Human Resource Management, Operations section. If the space furnished is insufficient, proper
abbreviation is permissible; if space is still insufficient, asterisk title blank and use Remarks, Item # 8.
School/Division - Medicine
The administrative area to which the employee's department reports.
Department - Surgery
The department to which the employee reports.
Dept. Code - NO149200
The PeopleSoft Department Code to which the employee reports.
Pay Grp. - NMF
The employee's pay group.
Empl. Cl. - 1 yr Trm
The employee's employee classification.
Pay Type - Salaried
The employee's pay type - ie. Salaried or Hourly
Reg/Temp - Regular
Indicates whether the employee is a regular or temporary employee.
Country - USA
Indicates the employee's country of citizenship. This field is not necessary for U.S. citizens.
Visa - J1
Indicates the type of visa permit the employee is on. This field is not necessary for US
citizens.
PROPOSED ACTION: The first step after completing the top part of the form is to mark (X)
the appropriate block (or blocks) indicating the action (or actions) being taken and fill in the
required information.
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(1) Termination
(a) Effective Date - This date is to be the effective date of termination that severs the individual from
the employee-employer relationship with the LSU Health Sciences Center. It is not to be confused with
the last day worked.
(b) Last Day cob.Worked - This should be the date of the last day of work at the close of business
(c.o.b.).
(c) Hours of annual leave for which pay is due - Show hours for which pay for annual leave is due.
(d) Reason - This line must be completed for the Health Sciences Center to comply with the
Unemployment Compensation Laws.
(2) Retirement
(a) Mark the correct box to indicate the type of retirement. Contact the Human Resource Management
retirement representative, should you have any questions concerning this section.
(b) Indicate the effective date of such retirement.
(3) Leave of Absence
(a) Effective - The date of the first working day the employee is absent.
(b) Thru -The last working day in which the employee is absent.
(c) With Pay/Without Pay - Mark the appropriate box.
(d) Justification - Include the type of leave, and also indicate the rate of pay - example: Sabbatical with
one-half pay. Refer to Permanent Memoranda #12.
(e) Insurance continued/discontinued - Mark the appropriate box so that the proper entries may be
made to the insurance records and make sure an insurance leave without pay form is completed and
submitted along with this form.
(4) Return from Leave of Absence effective - This is the first day the employee returns to work. It is
required that this action be prepared in every case when an employee returns to work from any type of
leave that required the processing of a form authorizing the leave.
(5) Transfer to New Department - This is the full name of the new department to which the employee
is assigned. Item # 6 must always be completed in addition to this section.
(a) Effective Date - The date of the actual change in duties and responsibility.
(b) LSU Work Location - Physical location where the employee is assigned to work.
(1) PS Location Code - The nine digit PeopleSoft code that is used for distribution of campus pay
checks and leave attendance sheets.
(2) PS Dept Code - The PS department code indicating the department in which the employee will be
working.
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(3) Phone # - The number where the employee can be contacted while at work.
(4) New PS. Pos. # - The new eight digit PeopleSoft Position number that the employee has been
assigned to.
(5) New PCN# - The position control number from the Operating Budget for the position being filled.
For multiple Position Control Numbers, please clarify in item #8, Remarks.
(6) Promotion and/or Change in Title to: The new title for either promotion or change should be
shown with the title conforming to instructions in item #5 above. A title can change without a
promotion in lateral moves. In a lateral transfer to a new department with no change in title it is not
necessary to complete this item #.
(a) Effective Date - Refers to 5(a) and, in addition, the time of the increase in pay should be considered.
(b) New Position Control Number should be typed in "remarks"
(c) Current/Last Incumbent - Mark the appropriate box.
(d) Justification - A brief explanation is sufficient.
(7) Tenure Recommendation (For Faculty Ranks) - This should be completed in only those
instances in which it is applicable , and in accordance with the Bylaws and Regulations of the Board of
Supervisors of Louisiana State University and Agricultural and Mechanical College, Chapter 11, page
33, TENURE. Note: This section is reserved for faculty on tenure track. Tenure information should be
supplied by the Department Head and/or Dean of each school. Do not attempt to complete this section
by yourself.
_______ yrs - The number of year(s) given to a faculty member on tenure track
Beginning ___ - The effective date of the extension for a faculty member on tenure track.
End Date - The last day of the extension and should be completed by the department.
(8) Other Changes or Remarks - This area is reserved for pertinent information not covered on the
form.
(9) Continuation of Appointment - This should be completed to continue employees that are currently
on periods of appointments that are about to expire or have changes.
(a) Last Appointment Effective ___ Thru___ - The dates as shown on the current Appointment or Per 3
form.
(b) This Appointment Effective ___ Thru ___ - The new dates to extend an appointment or to show a
new distribution or extension on restricted funds.
(10) Change in Source of Funds - Mark this box to indicate a change in source of funds and complete
item # 12.
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(11) Additional Compensation - This section is to be completed when an employee is paid for
performing duties in addition to or outside the normal areas of responsibility of his/her job. These
duties would be at the request of a Health Sciences Center Department and the funds would be paid
through the Health Sciences Center. All areas of this section must be completed. For further
information, please refer to PM-3.
(12) Salary And Distribution
Effective - The date in which the changes will begin.
Funds End Date - Used to indicate the through date for those appointments that are paid partially or
completely from grants or contracts.
AED - Appointment End Date - To be completed by the Human Resource Management Department.
Rate of Pay - The annual level amount divided by 12 or a specified amount when paid on a period of
appointment for unclassified, salaried employees. For bi-weekly or hourly employees, it is the hourly
rate. Mark the appropriate box for the employee's pay type.
On the Basis of - Mark the appropriate box to indicate the type of appointment.
Percent of full time - Indicate the current percent of full-time.
If Change: from ___ % to ___ % - Complete this section only when there is a change on percent effort.
LSU Account # - The Legacy Account Number where the funds will come from.
LSU Description - Brief description of the funding
Dept. Code # - The seven (7) digit PeopleSoft Department code for the funds
Fund - The three (3) digit funding code from the chart string that identifies the type of funding.
Program - The five (5) digit program code from the chart string that identifies the type of program.
Class - The five (5) digit class code from the chart string that identifies the type of class.
Project/Grant/ - This is the Project/grant number.
Account - The six (6) digit PeopleSoft Account code.
% Distribution - The proposed percentage of distribution of the proposed total salary that is derived
from the indicated funds.
Present and Proposed Amount - This amount of pay is to be the amount that a full-time employee
would receive on a full-time basis for a fiscal year. For those employees appointed for less than full-
time, their annual level should reflect the part-time annual amount for the fiscal year.
Totals - The sum of the present/proposed annual columns.
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To complete the form using data extracted from Queries
Go into Citrix and log onto PeopleSoft HR Report.
Go to "Go" , "PeopleTools, "Query". Once the Query panel is available, open the public
query labeled "LSUNOZZ_PER_3_GENERATOR" and choose the run link .
The query will prompt for the "position number", "Fiscal Year" and "Department ID". Enter the
PeopleSoft position number for the person you would like to complete the Per 3 on, followed by the
appropriate fiscal year in which the Per form is to be processed and the appropriate Department ID#
preceded with "NO"
Once the results appears, export to Excel and highlight the rows where the data begins. Once the data is
highlighted, go to Edit, and choose "Copy". Once the data is copied, go to the Excel workbook in which
the Per 3 form is located and click on the "datasheet" tab. Click on cell A2, go to "Edit" and "Paste"
(see Figure 1). The information from the query should appear on the datasheet. Go to the tab labeled
"Original" and check to see that all the information from the query for the person is on the form.
Figure
Figure 6 6
6
Figure
Figure 6 6
Figure 1
The information from the query should appear on the datasheet (see below).
7
Go to the tab labeled "Original" and check to see that all the information from the query for the person
is on the form. (see Figure 2).
Figure 2
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Complete the rest of the form - filling in all missing information. Preview the pages that make up the
set of forms (tabs include - Original (query), Personnel (query), Dept, (query), Sponsored Proj. (query),
and Dean-Dir (query)) to ensure that the form is fit to one page. Print the four tabs, staple, and route
through for approval.
Instructions for Retroactive Changes in Source of Funds
1. Check box 10 indicating that the Personnel Status Change Form (PER-3) is for a retroactive change
in source of funds (i.e. Salary Cost Transfer).
2. Enter the Beginning and Ending Check Dates in the Effective and Funds End Date fields under
section 12.
3. Enter the applicable Chartfields for the Present Amount and Proposed Amount. Only the Chartfields
for the Present Amount(s) and the Proposed Amount(s) that are being changed are required. The
listing of additional Chartfields is optional.
4. The Present Amount column should represent the exact amount that was charged to the applicable
project or unrestricted chartfield combination for the period indicated in Section 12. There is a query in
the PeopleSoft HR Reports database named LSU_EMP_SAL_DIST_BY_PERIOD that will provide
users with the current distribution for an employee for a given fiscal year by Check Date.
5. The Project/Grant Column must include the Speedtype for Fund 111 chartstrings to ensure timely
processing.
6. The Proposed Amount column must clearly indicate the distribution amount that is expected and it
must equal the total of the Present Amount column.
7. Separate PER-3s must be prepared for each Account. A PER-3 for account # 501000 (Salary-
Monthly-Regular Pay) cannot be included on a PER -3 for account # 501310(Salary-Mon-Extra Com-
Prof Care).
8. Once complete, all PER-3s for retroactive changes in source of funds must be routed to Susan
Arnold.
Rev 6/08
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Rev.12/07 LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - NEW ORLEANS CAMPUS Hourly
PERSONNEL STATUS CHANGE (PER 3 FORM)
Soc. Sec. #. Empl.ID PCN PS. Pos.
Name Present Title
Last First M.I
School/Division Dept. Dept. Code
last day
1. Termination effective cob.worked Hrs. annual leave for which pay is due
Reason
2. Retirement Regular Disability Effective Teacher's La. State Empl. Pay Grp. #N/A
Hours of unused leave to be applied to retirement: Annual Sick Emp. Cl. #N/A
Hours for which pay is due …………………….. Annual Sick Pay Type Hourly
3. Leave of Absence effective thru With pay Without Pay Reg/Temp Reg
Justification Ins. Cont. Discontinued Country #N/A
4. Return from Leave of Absence effective Visa #N/A
5. Transfer to New Dept. Effective
LSU Work Location
PS Location Code PS Dept . Code Phone # New PCN# New PS. Pos#
6. Promotion and/or Change in Title to Effective
Current Last Incumbent Justification
7. Tenure Recommendation ( For Faculty Ranks ) yr(s). Beginning End Date
Tenure Track Tenure Granted Probationary Non - Tenure
8. Other Changes or Remarks
9. Continuation of Appointment: Last Appointment Effective thru
This Appointment Effective thru
10. Change in Source of Funds
11. Additional Compensation: Total Amount Effective thru
Indicate Payment Dates and Amounts
Justification
12. SALARY AND DISTRIBUTION Effective Funds End Date AED
Rate of Pay from $ 0.00 to $ 0.00 On the Basis of : From To
X Hourly Monthly Per Period X Hourly Monthly Per Period Fiscal Year
Percent of full time %. If change: from % to % Period of Appt.
LSU Account LSU Description Dept. Code # Fund Program Class Project/ Grant Acct % Dist Present Proposed
# Amount Amount
Totals 0.00 0.00
Signed 12/13/2010 Approved
Initiating Officer Date Vice Chancellor Date
Approved Approved
Dean or Director Date Chancellor Date
Approved
Initials Date Initials Date Initials Date President Date
Rev. 12/07 LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - NEW ORLEANS CAMPUS Hourly
PERSONNEL STATUS CHANGE (PER 3 FORM)
Soc. Sec. #. Empl.ID PCN PS. Pos.
Name Present Title
Last First M.I
School/Division Dept. Dept. Code
last day
1. Termination effective cob.worked Hrs. annual leave for which pay is due
Reason
2. Retirement Regular Disability Effective Teacher's La. State Empl. Pay Grp. #N/A
Hours of unused leave to be applied to retirement: Annual Sick Emp. Cl. #N/A
Hours for which pay is due …………………….. Annual Sick Pay Type Hourly
3. Leave of Absence effective thru With pay Without Pay Reg/Temp Reg
Justification Ins. Cont. Discontinued Country #N/A
4. Return from Leave of Absence effective Visa #N/A
5. Transfer to New Dept. Effective
LSU Work Location
PS Location Code PS Dept . Code Phone # New PCN# New PS. Pos#
6. Promotion and/or Change in Title to Effective
Current Last Incumbent Justification
7. Tenure Recommendation ( For Faculty Ranks ) yr(s). Beginning End Date
Tenure Track Tenure Granted Probationary Non - Tenure
8. Other Changes or Remarks
9. Continuation of Appointment: Last Appointment Effective thru
This Appointment Effective thru
10. Change in Source of Funds
11. Additional Compensation: Total Amount Effective thru
Indicate Payment Dates and Amounts
Justification
12. SALARY AND DISTRIBUTION Effective Funds End Date AED
Rate of Pay from $ 0.00 to $ 0.00 On the Basis of : From To
X Hourly Monthly Per Period X Hourly Monthly Per Period Fiscal Year
Percent of full time %. If change: from % to % Period of Appt.
LSU Account LSU Description Dept. Code # Fund Program Class Project/ Grant Acct % Dist Present Proposed
# Amount Amount
Totals 0.00 0.00
Signed 12/13/2010 Approved
Initiating Officer Date Vice Chancellor Date
Approved Approved
Dean or Director Date Chancellor Date
Approved
Initials Date Initials Date Initials Date President Date
Rev. 12/07 LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - NEW ORLEANS CAMPUS Hourly
PERSONNEL STATUS CHANGE (PER 3 FORM)
Soc. Sec. #. Empl.ID PCN PS. Pos.
Name Present Title
Last First M.I
School/Division Dept. Dept. Code
last day
1. Termination effective cob.worked Hrs. annual leave for which pay is due
Reason
2. Retirement Regular Disability Effective Teacher's La. State Empl. Pay Grp. #N/A
Hours of unused leave to be applied to retirement: Annual Sick Emp. Cl. #N/A
Hours for which pay is due …………………….. Annual Sick Pay Type Hourly
3. Leave of Absence effective thru With pay Without Pay Reg/Temp Reg
Justification Ins. Cont. Discontinued Country #N/A
4. Return from Leave of Absence effective Visa #N/A
5. Transfer to New Dept. Effective
LSU Work Location
PS Location Code PS Dept . Code Phone # New PCN# New PS. Pos#
6. Promotion and/or Change in Title to Effective
Current Last Incumbent Justification
7. Tenure Recommendation ( For Faculty Ranks ) yr(s). Beginning End Date
Tenure Track Tenure Granted Probationary Non - Tenure
8. Other Changes or Remarks
9. Continuation of Appointment: Last Appointment Effective thru
This Appointment Effective thru
10. Change in Source of Funds
11. Additional Compensation: Total Amount Effective thru
Indicate Payment Dates and Amounts
Justification
12. SALARY AND DISTRIBUTION Effective Funds End Date AED
Rate of Pay from $ 0.00 to $ 0.00 On the Basis of : From To
X Hourly Monthly Per Period X Hourly Monthly Per Period Fiscal Year
Percent of full time %. If change: from % to % Period of Appt.
LSU Account LSU Description Dept. Code # Fund Program Class Project/ Grant Acct % Dist Present Proposed
# Amount Amount
Totals 0.00 0.00
Signed 12/13/2010 Approved
Initiating Officer Date Vice Chancellor Date
Approved Approved
Dean or Director Date Chancellor Date
Approved
Initials Date Initials Date Initials Date President Date
Rev. 12/07 LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - NEW ORLEANS CAMPUS Hourly
PERSONNEL STATUS CHANGE (PER 3 FORM)
Soc. Sec. #. Empl.ID PCN PS. Pos.
Name Present Title
Last First M.I
School/Division Dept. Dept. Code
last day
1. Termination effective cob.worked Hrs. annual leave for which pay is due
Reason
2. Retirement Regular Disability Effective Teacher's La. State Empl. Pay Grp. #N/A
Hours of unused leave to be applied to retirement: Annual Sick Emp. Cl. #N/A
Hours for which pay is due …………………….. Annual Sick Pay Type Hourly
3. Leave of Absence effective thru With pay Without Pay Reg/Temp Reg
Justification Ins. Cont. Discontinued Country #N/A
4. Return from Leave of Absence effective Visa #N/A
5. Transfer to New Dept. Effective
LSU Work Location
PS Location Code PS Dept . Code Phone # New PCN# New PS. Pos#
6. Promotion and/or Change in Title to Effective
Current Last Incumbent Justification
7. Tenure Recommendation ( For Faculty Ranks ) yr(s). Beginning End Date
Tenure Track Tenure Granted Probationary Non - Tenure
8. Other Changes or Remarks
9. Continuation of Appointment: Last Appointment Effective thru
This Appointment Effective thru
10. Change in Source of Funds
11. Additional Compensation: Total Amount Effective thru
Indicate Payment Dates and Amounts
Justification
12. SALARY AND DISTRIBUTION Effective Funds End Date AED
Rate of Pay from $ 0.00 to $ 0.00 On the Basis of : From To
X Hourly Monthly Per Period X Hourly Monthly Per Period Fiscal Year
Percent of full time %. If change: from % to % Period of Appt.
LSU Account LSU Description Dept. Code # Fund Program Class Project/ Grant Acct % Dist Present Proposed
# Amount Amount
Totals 0.00 0.00
Signed 12/13/2010 Approved
Initiating Officer Date Vice Chancellor Date
Approved Approved
Dean or Director Date Chancellor Date
Approved
Initials Date Initials Date Initials Date President Date
Rev. 12/07 LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - NEW ORLEANS CAMPUS Hourly
PERSONNEL STATUS CHANGE (PER 3 FORM)
Soc. Sec. #. Empl.ID PCN PS. Pos.
Name Present Title
Last First M.I
School/Division Dept. Dept. Code
last day
1. Termination effective cob.worked Hrs. annual leave for which pay is due
Reason
2. Retirement Regular Disability Effective Teacher's La. State Empl. Pay Grp. #N/A
Hours of unused leave to be applied to retirement: Annual Sick Emp. Cl. #N/A
Hours for which pay is due …………………….. Annual Sick Pay Type Hourly
3. Leave of Absence effective thru With pay Without Pay Reg/Temp Reg
Justification Ins. Cont. Discontinued Country #N/A
4. Return from Leave of Absence effective Visa #N/A
5. Transfer to New Dept. Effective
LSU Work Location
PS Location Code PS Dept . Code Phone # New PCN# New PS. Pos#
6. Promotion and/or Change in Title to Effective
Current Last Incumbent Justification
7. Tenure Recommendation ( For Faculty Ranks ) yr(s). Beginning End Date
Tenure Track Tenure Granted Probationary Non - Tenure
8. Other Changes or Remarks
9. Continuation of Appointment: Last Appointment Effective thru
This Appointment Effective thru
10. Change in Source of Funds
11. Additional Compensation: Total Amount Effective thru
Indicate Payment Dates and Amounts
Justification
12. SALARY AND DISTRIBUTION Effective Funds End Date AED
Rate of Pay from $ 0.00 to $ 0.00 On the Basis of : From To
X Hourly Monthly Per Period X Hourly Monthly Per Period Fiscal Year
Percent of full time %. If change: from % to % Period of Appt.
LSU Account LSU Description Dept. Code # Fund Program Class Project/ Grant Acct % Dist Present Proposed
# Amount Amount
Totals 0.00 0.00
Signed 12/13/2010 Approved
Initiating Officer Date Vice Chancellor Date
Approved Approved
Dean or Director Date Chancellor Date
Approved
Initials Date Initials Date Initials Date President Date
Acct Code Distrb % Name Job Title NID ID
0674000001-501000 100.00 Doe,John 123456789
MANAGER - HUMAN RESOURCE MANAG 12345
DeptID Hrly Rate Monthly Rt Annual Rt FTE Reg/Temp Empl Class Status Position
NO1674000 20.19 3,500.00 42,000.00 1.00 Regular Indf No Tn Active 123456
Dept Group Type Mail Drop Class Fund Program DeptID Proj/Grt Acct Last Name
NBN
Human resource management Hourly 48460001 10105 111 54000 1674000 501000 Doe
First Name Status
John Native
Rev. 12/07 LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - NEW ORLEANS CAMPUS Hourly
PERSONNEL STATUS CHANGE (PER 3 FORM)
Soc. Sec. #. 123-45-6789 Empl.ID 0012345 PCN 0048460001 PS. Pos. 00123456
Name Doe John Present Title MANAGER - HUMAN RESOURCE MANAG
Last First M.I
School/Division Dept. Human resource management Dept. Code NO1674000
last day
1. Termination effective cob.worked Hrs. annual leave for which pay is due
Reason
2. Retirement Regular Disability Effective Teacher's La. State Empl. Pay Grp. NBN
Hours of unused leave to be applied to retirement: Annual Sick Emp. Cl. Indf No Tn
Hours for which pay is due …………………….. Annual Sick Pay Type Hourly
3. Leave of Absence effective thru With pay Without Pay Reg/Temp Regular
Justification Ins. Cont. Discontinued Country #N/A
4. Return from Leave of Absence effective Visa Native
5. Transfer to New Dept. Effective
LSU Work Location
PS Location Code PS Dept . Code Phone # New PCN# New PS. Pos#
6. Promotion and/or Change in Title to Effective
Current Last Incumbent Justification
7. Tenure Recommendation ( For Faculty Ranks ) yr(s). Beginning End Date
Tenure Track Tenure Granted Probationary Non - Tenure
8. Other Changes or Remarks
9. Continuation of Appointment: Last Appointment Effective thru
This Appointment Effective thru
10. Change in Source of Funds
11. Additional Compensation: Total Amount Effective thru
Indicate Payment Dates and Amounts
Justification
12. SALARY AND DISTRIBUTION Effective Funds End Date AED
Rate of Pay from $ 20.19 to $ 0.00 On the Basis of : From To
X Hourly Monthly Per Period X Hourly Monthly Per Period Fiscal Year
Percent of full time 100 %. If change: from % to % Period of Appt.
LSU Account LSU Description Dept. Code # Fund Program Class Project/ Grant Acct % Dist Present Proposed
# Amount Amount
1674000 111 54000 10105 501000 42,000.00
Totals 42,000.00 0.00
Signed 12/13/2010 Approved
Initiating Officer Date Vice Chancellor Date
Approved Approved
Dean or Director Date Chancellor Date
Approved
Initials Date Initials Date Initials Date President Date
Rev. 12/07 LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - NEW ORLEANS CAMPUS Hourly
PERSONNEL STATUS CHANGE (PER 3 FORM)
Soc. Sec. #. 123-45-6789 Empl.ID 0012345 PCN 0048460001 PS. Pos. 00123456
Name Doe John Present Title MANAGER - HUMAN RESOURCE MANAG
Last First M.I
School/Division Dept. Human resource management Dept. Code NO1674000
last day
1. Termination effective cob.worked Hrs. annual leave for which pay is due
Reason
2. Retirement Regular Disability Effective Teacher's La. State Empl. Pay Grp. NBN
Hours of unused leave to be applied to retirement: Annual Sick Emp. Cl. Indf No Tn
Hours for which pay is due …………………….. Annual Sick Pay Type Hourly
3. Leave of Absence effective thru With pay Without Pay Reg/Temp Regular
Justification Ins. Cont. Discontinued Country #N/A
4. Return from Leave of Absence effective Visa Native
5. Transfer to New Dept. Effective
LSU Work Location
PS Location Code PS Dept . Code Phone # New PCN# New PS. Pos#
6. Promotion and/or Change in Title to Effective
Current Last Incumbent Justification
7. Tenure Recommendation ( For Faculty Ranks ) yr(s). Beginning End Date
Tenure Track Tenure Granted Probationary Non - Tenure
8. Other Changes or Remarks
9. Continuation of Appointment: Last Appointment Effective thru
This Appointment Effective thru
10. Change in Source of Funds
11. Additional Compensation: Total Amount Effective thru
Indicate Payment Dates and Amounts
Justification
12. SALARY AND DISTRIBUTION Effective Funds End Date AED
Rate of Pay from $ 20.19 to $ 0.00 On the Basis of : From To
X Hourly Monthly Per Period X Hourly Monthly Per Period Fiscal Year
Percent of full time 100 %. If change: from % to % Period of Appt.
LSU Account LSU Description Dept. Code # Fund Program Class Project/ Grant Acct % Dist Present Proposed
# Amount Amount
1674000 111 54000 10105 501000 42,000.00
Totals 42,000.00 0.00
Signed 12/13/2010 Approved
Initiating Officer Date Vice Chancellor Date
Approved Approved
Dean or Director Date Chancellor Date
Approved
Initials Date Initials Date Initials Date President Date
Rev. 12/07 LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - NEW ORLEANS CAMPUS Hourly
PERSONNEL STATUS CHANGE (PER 3 FORM)
Soc. Sec. #. 123-45-6789 Empl.ID 0012345 PCN 0048460001 PS. Pos. 00123456
Name Doe John Present Title MANAGER - HUMAN RESOURCE MANAG
Last First M.I
School/Division Dept. Human resource management Dept. Code NO1674000
last day
1. Termination effective cob.worked Hrs. annual leave for which pay is due
Reason
2. Retirement Regular Disability Effective Teacher's La. State Empl. Pay Grp. NBN
Hours of unused leave to be applied to retirement: Annual Sick Emp. Cl. Indf No Tn
Hours for which pay is due …………………….. Annual Sick Pay Type Hourly
3. Leave of Absence effective thru With pay Without Pay Reg/Temp Regular
Justification Ins. Cont. Discontinued Country #N/A
4. Return from Leave of Absence effective Visa Native
5. Transfer to New Dept. Effective
LSU Work Location
PS Location Code PS Dept . Code Phone # New PCN# New PS. Pos#
6. Promotion and/or Change in Title to Effective
Current Last Incumbent Justification
7. Tenure Recommendation ( For Faculty Ranks ) yr(s). Beginning End Date
Tenure Track Tenure Granted Probationary Non - Tenure
8. Other Changes or Remarks
9. Continuation of Appointment: Last Appointment Effective thru
This Appointment Effective thru
10. Change in Source of Funds
11. Additional Compensation: Total Amount Effective thru
Indicate Payment Dates and Amounts
Justification
12. SALARY AND DISTRIBUTION Effective Funds End Date AED
Rate of Pay from $ 20.19 to $ 0.00 On the Basis of : From To
X Hourly Monthly Per Period X Hourly Monthly Per Period Fiscal Year
Percent of full time 100 %. If change: from % to % Period of Appt.
LSU Account LSU Description Dept. Code # Fund Program Class Project/ Grant Acct % Dist Present Proposed
# Amount Amount
1674000 111 54000 10105 501000 42,000.00
Totals 42,000.00 0.00
Signed 12/13/2010 Approved
Initiating Officer Date Vice Chancellor Date
Approved Approved
Dean or Director Date Chancellor Date
Approved
Initials Date Initials Date Initials Date President Date
Rev. 12/07 LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - NEW ORLEANS CAMPUS Hourly
PERSONNEL STATUS CHANGE (PER 3 FORM)
Soc. Sec. #. 123-45-6789 Empl.ID 0012345 PCN 0048460001 PS. Pos. 00123456
Name Doe John Present Title MANAGER - HUMAN RESOURCE MANAG
Last First M.I
School/Division Dept. Human resource management Dept. Code NO1674000
last day
1. Termination effective cob.worked Hrs. annual leave for which pay is due
Reason
2. Retirement Regular Disability Effective Teacher's La. State Empl. Pay Grp. NBN
Hours of unused leave to be applied to retirement: Annual Sick Emp. Cl. Indf No Tn
Hours for which pay is due …………………….. Annual Sick Pay Type Hourly
3. Leave of Absence effective thru With pay Without Pay Reg/Temp Regular
Justification Ins. Cont. Discontinued Country #N/A
4. Return from Leave of Absence effective Visa Native
5. Transfer to New Dept. Effective
LSU Work Location
PS Location Code PS Dept . Code Phone # New PCN# New PS. Pos#
6. Promotion and/or Change in Title to Effective
Current Last Incumbent Justification
7. Tenure Recommendation ( For Faculty Ranks ) yr(s). Beginning End Date
Tenure Track Tenure Granted Probationary Non - Tenure
8. Other Changes or Remarks
9. Continuation of Appointment: Last Appointment Effective thru
This Appointment Effective thru
10. Change in Source of Funds
11. Additional Compensation: Total Amount Effective thru
Indicate Payment Dates and Amounts
Justification
12. SALARY AND DISTRIBUTION Effective Funds End Date AED
Rate of Pay from $ 20.19 to $ 0.00 On the Basis of : From To
X Hourly Monthly Per Period X Hourly Monthly Per Period Fiscal Year
Percent of full time 100 %. If change: from % to % Period of Appt.
LSU Account LSU Description Dept. Code # Fund Program Class Project/ Grant Acct % Dist Present Proposed
# Amount Amount
1674000 111 54000 10105 501000 42,000.00
Totals 42,000.00 0.00
Signed 12/13/2010 Approved
Initiating Officer Date Vice Chancellor Date
Approved Approved
Dean or Director Date Chancellor Date
Approved
Initials Date Initials Date Initials Date President Date
Rev. 12/07 LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - NEW ORLEANS CAMPUS Hourly
PERSONNEL STATUS CHANGE (PER 3 FORM)
Soc. Sec. #. 123-45-6789 Empl.ID 0012345 PCN 0048460001 PS. Pos. 00123456
Name Doe John Present Title MANAGER - HUMAN RESOURCE MANAG
Last First M.I
School/Division Dept. Human resource management Dept. Code NO1674000
last day
1. Termination effective cob.worked Hrs. annual leave for which pay is due
Reason
2. Retirement Regular Disability Effective Teacher's La. State Empl. Pay Grp. NBN
Hours of unused leave to be applied to retirement: Annual Sick Emp. Cl. Indf No Tn
Hours for which pay is due …………………….. Annual Sick Pay Type Hourly
3. Leave of Absence effective thru With pay Without Pay Reg/Temp Regular
Justification Ins. Cont. Discontinued Country #N/A
4. Return from Leave of Absence effective Visa Native
5. Transfer to New Dept. Effective
LSU Work Location
PS Location Code PS Dept . Code Phone # New PCN# New PS. Pos#
6. Promotion and/or Change in Title to Effective
Current Last Incumbent Justification
7. Tenure Recommendation ( For Faculty Ranks ) yr(s). Beginning End Date
Tenure Track Tenure Granted Probationary Non - Tenure
8. Other Changes or Remarks
9. Continuation of Appointment: Last Appointment Effective thru
This Appointment Effective thru
10. Change in Source of Funds
11. Additional Compensation: Total Amount Effective thru
Indicate Payment Dates and Amounts
Justification
12. SALARY AND DISTRIBUTION Effective Funds End Date AED
Rate of Pay from $ 20.19 to $ 0.00 On the Basis of : From To
X Hourly Monthly Per Period X Hourly Monthly Per Period Fiscal Year
Percent of full time 100 %. If change: from % to % Period of Appt.
LSU Account LSU Description Dept. Code # Fund Program Class Project/ Grant Acct % Dist Present Proposed
# Amount Amount
1674000 111 54000 10105 501000 42,000.00
Totals 42,000.00 0.00
Signed 12/13/2010 Approved
Initiating Officer Date Vice Chancellor Date
Approved Approved
Dean or Director Date Chancellor Date
Approved
Initials Date Initials Date Initials Date President Date
Pay
Pay Groups Empl Class
Groups
1 GR1 GR1 - Gratis 1 1 Year Trm
2 NBD NBD - To be determined 2 2 Year Trm
3 NBE NBE - New Orleans Bi Weekly Exempt 3 3 Year Trm
4 NBN NBN - Biweekly/Non-Exempt 4 Ann No Ten
5 NBR NBR - Residents (NO) 5 Grd No Ten
6 NBS NBS - New Orleans Students 6 Indf No Tn
7 NBT NBT - Transients/Restricted 7 Job
8 NMF NMF - Full-time Faculty Staff (NO) 8 Permanent
9 NMG NMG - Graduate Assistants (NO) 9 POA
10 NML NML - Fellows (NO) 10 Probation
11 NMP NMP - Part-time Faculty/Staff (NO) 11 Provision
12 NMS NMS - New Orleans Stipend 12 Resident
13 NRT NRT - New Orleans Retirees 13 Rest Appt
14 Student
15 Tenured
16 Transient
17 Unclass
Pay Reg/
Empl Class Number Cntry Short Desc Number Visa
Type Temp
1 Year Trm - 1 Year Term Salary Reg 1 ABW Aruba 1A
2 Year Trm - 2 Year Term Hourly Temp 2 AFG Afghanistn 2 AR1
3 Year Trm - 3 Year Term 3 AGO Angola 3 B1
Ann No Ten - Annual/No Tenure Rights 4 AIA Anguilla 4 B2
Grd No Ten - Graduate Assistant No Tenure 5 ALB Albania 5C
Indf No Tn - Indefinite/No Tenure 6 AND Andorra 6D
Job - Job 7 ANT Nth Antill 7E
Permanent - Permanent 8 ARE UEA 8 EA
POA - Period of Appointment 9 ARG Argentina 9 EAD
Probation - Probational 10 ARM Armenia 10 F1
Provision - Provisional 11 ASM Am Samoa 11 F2
Resident - Resident 12 ATA Antarctica 12 FN
Rest Appt - Restricted Appointment 13 ATF Fr S Terr 13 G
Student - Student 14 ATG Antigua 14 H1
Tenured - Tenured 15 AUS Australia 15 H1B
Transient - Transient 16 AUT Austria 16 H1C
Unclass - Unclassified 17 AZE Azerbaijan 17 H2A
18 BDI Burundi 18 H2B
19 BEL Belgium 19 H3
20 BEN Benin 20 H4
21 BFA Burkina F 21 I
22 BGD Bangladesh 22 J1
23 BGR Bulgaria 23 J1C
24 BHR Bahrain 24 J1R
25 BHS Bahamas 25 J1S
26 BIH Bosnia Her 26 J2
27 BLR Belarus 27 L1
28 BLZ Belize 28 L2
29 BMU Bermuda 29 M1
30 BOL Bolivia 30 M2
31 BRA Brazil 31 ML
32 BRB Barbados 32 NAT
33 BRN Brunei 33 O1
34 BTN Bhutan 34 O2
35 BVT Bouvet Is. 35 O3
36 BWA Botswana 36 P
37 CAF Central Af 37 Q
38 CAN Canada 38 R1
39 CCK Cocos Is. 39 R2
40 CHE Switzerlan 40 RA
41 CHL Chile 41 S
42 CHN China 42 STP
43 CIV Cote D'Ivo 43 TD
44 CMR Cameroon 44 TN
45 COD Congo, The 45 TR
46 COG Congo 46 VWB
47 COK Cook Is. 47 VWT
48 COL Colombia 48 Native
49 COM Comoros
50 CPV Cape Verde
51 CRI Costa Rica
52 CUB Cuba
53 CXR Christmas
54 CYM Cayman Is.
55 CYP Cyprus
56 CZE Czech Rep
57 DEU Germany
58 DJI Djibouti
59 DMA Dominica
60 DNK Denmark
61 DOM Dominican
62 DZA Algeria
63 ECU Ecuador
64 EGY Egypt
65 ERI Eritrea
66 ESH W Sahara
67 ESP Spain
68 EST Estonia
69 ETH Ethiopia
70 FIN Finland
71 FJI Fiji
72 FLK Falkland I
73 FRA France
74 FRO Faroe Is.
75 FSM Micronesia
76 GAB Gabon
77 GBR UK
78 GEO Georgia
79 GHA Ghana
80 GIB Gibraltar
81 GIN Guinea
82 GLP Guadeloupe
83 GMB Gambia
84 GNB Guinea-Bis
85 GNQ Guinea
86 GRC Greece
87 GRD Grenada
88 GRL Greenland
89 GTM Guatemala
90 GUF Fr Guiana
91 GUM Guam
92 GUY Guyana
93 HKG Hong Kong
94 HMD Heard Is
95 HND Honduras
96 HRV Croatia
97 HTI Haiti
98 HUN Hungary
99 IDN Indonesia
100 IND India
101 IOT BritishIOT
102 IRL Ireland
103 IRN Iran
104 IRQ Iraq
105 ISL Iceland
106 ISR Israel
107 ITA Italy
108 JAM Jamaica
109 JOR Jordan
110 JPN Japan
111 KAZ Kazakstan
112 KEN Kenya
113 KGZ Kyrgyzstan
114 KHM Cambodia
115 KIR Kiribati
116 KNA St Kitts
117 KOR Sth Korea
118 KWT Kuwait
119 LAO Lao
120 LBN Lebanon
121 LBR Liberia
122 LBY Libyan Ara
123 LCA St Lucia
124 LIE Liechtenst
125 LKA Sri Lanka
126 LSO Lesotho
127 LTU Lithuania
128 LUX Luxembourg
129 LVA Latvia
130 MAC Macau
131 MAR Morocco
132 MCO Monaco
133 MDA Moldova
134 MDG Madagascar
135 MDV Maldives
136 MEX Mexico
137 MHL Marshall I
138 MKD Macedonia
139 MLI Mali
140 MLT Malta
141 MMR Myanmar
142 MNG Mongolia
143 MNP N Marina I
144 MOZ Mozambique
145 MRT Mauritania
146 MSR Montserrat
147 MTQ Martinique
148 MUS Mauritius
149 MWI Malawi
150 MYS Malaysia
151 MYT Mayotte
152 NAM Namibia
153 NCL New Caledo
154 NER Niger
155 NFK Norfolk Is
156 NGA Nigeria
157 NIC Nicaragua
158 NIU Niue
159 NLD Netherland
160 NOR Norway
161 NPL Nepal
162 NRU Nauru
163 NZL NZ
164 OMN Oman
165 PAK Pakistan
166 PAN Panama
167 PCN Pitcairn
168 PER Peru
169 PHL Philippine
170 PLW Palau
171 PNG PNG
172 POL Poland
173 PRI Puerto Rco
174 PRK Nth Korea
175 PRT Portugal
176 PRY Paraguay
177 PYF Fr Polynes
178 QAT Qatar
179 REU Reunion
180 ROM Romania
181 RUS Russian Fd
182 RWA Rwanda
183 SAU Saudi Arab
184 SDN Sudan
185 SEN Senegal
186 SGP Singapore
187 SGS S Georgia
188 SHN St Helena
189 SJM Svalbard
190 SLB Solomon Is
191 SLE Sierra Leo
192 SLV ElSalvador
193 SMR San Marino
194 SOM Somalia
195 SPM St Pierre
196 STP Sao Tome
197 SUR Suriname
198 SVK Slovakia
199 SVN Slovenia
200 SWE Sweden
201 SWZ Swaziland
202 SYC Seychelles
203 SYR Syrian Ara
204 TCA Turks Is
205 TCD Chad
206 TGO Togo
207 THA Thailand
208 TJK Tajikistan
209 TKL Tokelau
210 TKM Turkmenstn
211 TMP East Timor
212 TON Tonga
213 TTO Trinidad
214 TUN Tunisia
215 TUR Turkey
216 TUV Tuvalu
217 TWN Taiwan
218 TZA Tanzania,
219 UGA Uganda
220 UKR Ukraine
221 UMI US Islands
222 URY Uruguay
223 USA USA
224 UZB Uzbekistan
225 VAT Vatican
226 VCT St Vincent
227 VEN Venezuela
228 VGB BrVirginIs
229 VIR VirginIsUS
230 VNM Viet Nam
231 VUT Vanuatu
232 WLF Wallis and
233 WSM Samoa
234 YEM Yemen
235 YUG Yugoslavia
236 ZAF Sth Africa
237 ZMB Zambia
238 ZWE Zimbabwe
Short Desc
A - ForeignDip
AR1 - Alien Reg
B1 - VisitorBus
B2 - VisitorTou
C - AlienTr1-3
D - AlCrewD1-2
E - TreatyT/I
EA - Emp Author
EAD - EmpolyADoc
F1 - Student
F2 - Depend F1
FN - ForeignNat
G - RepOrgG1-3
H1 - temp. Wker
H1B - TempWorkSO
H1C - TempWkNur
H2A - AgriWorker
H2B - Skill/UnSk
H3 - Trainee
H4 - Depend H
I - RepFIMedia
J1 - Exchange V
J1 C - ExhVis-Cln
J1R - ExhVis-Res
J1S - ExhVis-Stu
J2 - Depend J1
L1 - Intracompa
L2 - Depend L1
M1 - Vocat Stud
M2 - Dep VocStu
ML - Act MMU
NAT - NATO 1-7
O1 - Person-EA
O2 - AccPer-O1
O3 - DepO1orO2
P - A/E/A P1-4
Q - PartCulExP
R1 - Relig Work
R2 - Depend R1
RA - ResAlien
S - AALE S5-S7
STP - I-551Stamp
TD - Depend TN
TN - Trade NAFT
TR - Temp Evide
VWB - VisaWaivBu
VWT - VISAWaivTu
Native
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