Form PER-4 "Provisional Appointment Request Form" - Connecticut

What Is Form PER-4?

This is a legal form that was released by the Connecticut State Department of Administrative Services - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2016;
  • The latest edition provided by the Connecticut State Department of Administrative Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form PER-4 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Administrative Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form PER-4 "Provisional Appointment Request Form" - Connecticut

547 times
Rate (4.8 / 5) 33 votes
State of Connecticut Human Resources
Provisional Appointment Request Form
Form #: PER-4
Revision Date: 02/2016
Agency __________________________________________________________________________________
Location of position: Facility/Dept _____________________________ Town/City _____________________
Full or part time ____________________________ Number of hours per week ________________________
Class Title __________________________________________________ Class Code ___________________
Section 5-235(a) of the Connecticut General Statutes states: When a candidate list provided under section 5-215a
contains fewer than five candidates, in order to facilitate the carrying on of public business or avoid inconvenience to the
public, but not otherwise, the Commissioner of Administrative Services may authorize the filling of the position at once by
provisional appointment, pending the establishment of a reemployment or candidate list.
Any such provisional
appointment shall continue only until a reemployment or candidate list for such position is established and, in no case, for
a period exceeding a total of six months. No person shall receive more than one provisional appointment or serve more
than six months as a provisional appointee in any one fiscal year.
A. RECLASSIFICATION OR VACANT POSITION
Is this a reclassification of a filled position?
Yes
No
If yes, skip to Section D. If no, complete all sections on the form. (A provisional appointment is not needed
if the appointment is being made to an unclassified or noncompetitive class or if all of the criteria of Section
5-227a are met.)
B. REPORT ON CURRENT LISTS
Is a reemployment list available?
Yes
No
Date checked on APS _____________
Is a SEBAC list available?
Yes
No
Date checked on APS _____________
Note:
It is the agency’s responsibility to check reemployment lists immediately prior to offering an
appointment. Agencies must also recheck SEBAC lists prior to offering an appointment if more than 21
calendar days have elapsed since the initial list was requested.
If you answered yes to either of the above questions, documentation must be provided supporting the contact
of the individuals on the list(s) and their waiver(s) of the position. Copies of the list(s) must be attached.
Explanation:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Is there a candidate list available?
Yes
No
Date checked on APS __________
If yes, how many names appear on the list? _________
If yes, detail the reasons why the candidate(s) on the list cannot meet the requirements of the position.
(Documentation must be provided supporting the contact of the individuals on the lists and their waiver(s) of
the position. Copies of the list must be attached.)
_______________________________________________________________________________________________
_______________________________________________________________________________________________
This form provided by the Department of Administrative Services
State of Connecticut Human Resources
Provisional Appointment Request Form
Form #: PER-4
Revision Date: 02/2016
Agency __________________________________________________________________________________
Location of position: Facility/Dept _____________________________ Town/City _____________________
Full or part time ____________________________ Number of hours per week ________________________
Class Title __________________________________________________ Class Code ___________________
Section 5-235(a) of the Connecticut General Statutes states: When a candidate list provided under section 5-215a
contains fewer than five candidates, in order to facilitate the carrying on of public business or avoid inconvenience to the
public, but not otherwise, the Commissioner of Administrative Services may authorize the filling of the position at once by
provisional appointment, pending the establishment of a reemployment or candidate list.
Any such provisional
appointment shall continue only until a reemployment or candidate list for such position is established and, in no case, for
a period exceeding a total of six months. No person shall receive more than one provisional appointment or serve more
than six months as a provisional appointee in any one fiscal year.
A. RECLASSIFICATION OR VACANT POSITION
Is this a reclassification of a filled position?
Yes
No
If yes, skip to Section D. If no, complete all sections on the form. (A provisional appointment is not needed
if the appointment is being made to an unclassified or noncompetitive class or if all of the criteria of Section
5-227a are met.)
B. REPORT ON CURRENT LISTS
Is a reemployment list available?
Yes
No
Date checked on APS _____________
Is a SEBAC list available?
Yes
No
Date checked on APS _____________
Note:
It is the agency’s responsibility to check reemployment lists immediately prior to offering an
appointment. Agencies must also recheck SEBAC lists prior to offering an appointment if more than 21
calendar days have elapsed since the initial list was requested.
If you answered yes to either of the above questions, documentation must be provided supporting the contact
of the individuals on the list(s) and their waiver(s) of the position. Copies of the list(s) must be attached.
Explanation:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Is there a candidate list available?
Yes
No
Date checked on APS __________
If yes, how many names appear on the list? _________
If yes, detail the reasons why the candidate(s) on the list cannot meet the requirements of the position.
(Documentation must be provided supporting the contact of the individuals on the lists and their waiver(s) of
the position. Copies of the list must be attached.)
_______________________________________________________________________________________________
_______________________________________________________________________________________________
This form provided by the Department of Administrative Services
C. JUSTIFICATION FOR THE PROVISIONAL REQUEST
A justification must be provided detailing the reasons that this position must be filled provisionally and why the
agency cannot wait for a candidate list to be promulgated in order to fill the position permanently.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
D. OTHER INFORMATION
Anticipated effective date of provisional, assuming DAS approval _______________
(Retro approval will only be granted if it is a result of a grievance or other legal action. A copy of the decision must be attached.)
Do you have OPM approval to fill the position?
Yes
No
Is an application attached?
Yes
No
(Include a PLD-1 if an applicant has been identified. The
applicant’s PLD-1 must be reviewed and approved by DAS prior to an offer being made.)
An Exam Request Form (P9) must be attached.
Agency Contact Person _________________________ Phone # _______________ Fax # ________________
Signature __________________________________________
Date _______________________________
The PER-4 Form and all required documents can be faxed to 860-622-2618 (fax is the preferred method)
e-mailed to: delegation.program@ct.gov or mailed to to DAS-Statewide Human Resources Management,
450 Columbus Boulvard, Hartford, CT 06103
DAS COMPLETES THIS SECTION
Date provisional request received ______________
Request to fill the position provisionally is: Approved _______
Denied ______
The provisional candidate meets the minimum E&T?
Yes
No
Minimum qualifications not reviewed; application not included in the package ______
Comments:
Signature __________________________________________
Date _______________________________
This form provided by the Department of Administrative Services
Page of 2