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Form

Employee Change of Status Form

Download:


Employee  name: ______________________________________________

Effective date: ____________________ Today's date: ________________


Instructions: Check the appropriate box and fill in the information below.

[] Initial hire

[] Transfer

[] Promotion

[] Termination

[] Benefit change

[] Wage change

[] Payroll deduction

[] Classification/status

[] Address change

[] Phone change

[] Leave of absence

[] Other: 


EMPLOYMENT CHANGES

New job title: ______________________________________

New classification:     [] Full-time       [] Part-time

New wage rate: __________     Percentage change: _____

New status:  [] Exempt     [] Nonexempt

New manager/department: ________________________

Instructions: _________________________

BENEFIT CHANGES
Benefits Affected:      [] Medical [] Dental [] LTD [] Life [] 401(k)

Instructions: ________________________________________________________

Signatures: (Employee signature is necessary only if a payroll deduction is required. Supervisor and director sign in all cases.)

 

Supervisor: ____________________________         Date: ___________________

Director: ______________________________         Date: ___________________

Employee (if applicable): __________________         Date: ___________________

 

To be completed by human resources:

Changes completed by: _________________           Date: ____________________

Payroll updated by: _____________________          Date: ____________________



Compensation
Employee Relations
Payroll
Policies and Practices

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