EMPLOYEE STATUS CHANGE
Name __________________________
Employer I.D. # __________________________
Department __________________________
Effective Date ________________
Wage/Salary/Title Change:
Title Grade Pay Rate
Increase %
Present
________________
___________ ___________ _________
Proposed
________________
___________
___________ _________
Type of Change: (check appropriate type)
[ ] New
Hire [ ] Voluntary Resignation
[ ] Promotion [
] Leave of Absence
[ ] Sick
Leave [ ] Transfer [ ] Return from Absence [
] Termination
[ ]
Layoff [ ] Disability - Non-Work
[ ] Disability - Work
If leave of absence, state duration - From
___________ To ___________
Comments and reasons for change:
_______________________________________
___________________________________________________________________
___________________________________________________________________
__________________________________________________________________.
Submitted by:
Supervisor _____________________ Title ___________ Date ______________
Approvals:
Department Manager _________________________ Date __________________
Personnel Manager ___________________________ Date __________________
Original to Department
Manager, copy to Personnel File.
