Employee name: ______________________ Date: ___________________
Department: _________________________ Job title: _________________
Type of Action
[] Job change [] Organization change [] Compensation [] Leave of absence [] Termination [] Other
| COMPLETE ONLY THOSE SECTIONS WHERE CHANGES APPLY | ||
|---|---|---|
| Current | Change to | |
| Job Information | ||
Title | ||
Job code | ||
Grade level | ||
Regular/temporary | ||
Full-time/part-time | ||
| Other: | | |
Organization Information | ||
Department | ||
Supervisor name | ||
HR contact name | ||
| Location | | |
Other: | ||
Compensation Information
| Current base | Merit | Promotion | Other | New base |
| $ _______________ | % Amount | % Amount | % Amount | $ _______________ |
| Premium Pay | Performance Level | ||
|---|---|---|---|
| [] Lead _____ | [] Subtract _____% | [] 1. Ineffective | [] 4. Exceeds Expectations |
| [] Shift_____ | [] Add _____% | [] 2. Needs Improvement | [] 5. Exceptional |
| [] 3. Proficient | |||
Leave Information
| [] Medical | [] Personal |
| [] Family | [] Other __________ |
Expected date of return _____/_____/____
Termination Information
Termination code ________________________
Eligible for re-hire? [] Yes [] No
Comments:
Signatures
Current manager name: ____________________________________________________
Current manager signature: _________________________________ Date: __________
Human resources contact name: ______________________________________________
Human resources signature: _________________________________ Date: __________
For HR Use Only
Reviewed by: ______________________________ Date: ____________
Changes made by: __________________________ Date: ____________
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