Employee Status Change Request Form

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Employee Status Change
Request Form
To be completed by Supervisor. Submission of this request does not give Supervisor authority to make any
changes. Supervisor must wait for response from HR Department.
Employee: __________________________________________
Currently paid out of: (program, code, %)
Program
Code
%
________
_________
______
Current Work Location:________________________________
________
_________
______
Current position:_____________________________________
________
_________
______
Employees Current ADP Supervisor:___________________
________
_________
______
Changes/additions requested
_____ Additional work hours
from ___________ to ___________
To be paid out of: (program, code, %)
_____ Add another position in addition to current _________________________
________
_________
______
________
_________
______
_____ Change in work hours
from ___________ to ___________
________
_________
______
_____ Change in work weeks/yr
from ___________ to ___________
________
_________
______
_____ Change in location
from ___________ to ___________
________
_________
______
_____ Change in position
from ___________ to ___________
________
_________
______
_____ Change in rate of pay
from ___________ to ___________
________
_________
______
Effective date of change: __________________________________
Employees New ADP Supervisor
Information to be entered into ADP:
_______________________________________
Specific Daily Hours for position: M____________T____________W____________Th____________F____________
Clearance(s) needed: (circle appropriate)
Fingerprint/Waiver
Daycare license#_____________
Unified Court System Program code: _ - _ _ _ _ _ - _ _ _ - _
SCR
Daycare license#_____________ Occumed—Medical/PPD Program code: _ - _ _ _ _ _ - _ _ _ -
Choicepoint Program code: _ - _ _ _ _ _ - _ _ _ - _
SS#__________ DOB________ Addresss__________________________
Reason for all requested changes: (please be as specific as possible including names etc.)
Supervisor filling out form Signature_______________________________ Date_____________________________
Director’s Approval Signature____________________________________ Date_____________________________
For HR Department use only:
__________ Approved—Effective date ____________
__________ Denied
- Reason _____________________________________
HR Dept. Signature
__________________________________
Date:
__________________________________
** Form to be used for current Employee CHANGES or ADDITIONS
updated: 11/6/2012
Employee Status Change
Request Form
To be completed by Supervisor. Submission of this request does not give Supervisor authority to make any
changes. Supervisor must wait for response from HR Department.
Employee: __________________________________________
Currently paid out of: (program, code, %)
Program
Code
%
________
_________
______
Current Work Location:________________________________
________
_________
______
Current position:_____________________________________
________
_________
______
Employees Current ADP Supervisor:___________________
________
_________
______
Changes/additions requested
_____ Additional work hours
from ___________ to ___________
To be paid out of: (program, code, %)
_____ Add another position in addition to current _________________________
________
_________
______
________
_________
______
_____ Change in work hours
from ___________ to ___________
________
_________
______
_____ Change in work weeks/yr
from ___________ to ___________
________
_________
______
_____ Change in location
from ___________ to ___________
________
_________
______
_____ Change in position
from ___________ to ___________
________
_________
______
_____ Change in rate of pay
from ___________ to ___________
________
_________
______
Effective date of change: __________________________________
Employees New ADP Supervisor
Information to be entered into ADP:
_______________________________________
Specific Daily Hours for position: M____________T____________W____________Th____________F____________
Clearance(s) needed: (circle appropriate)
Fingerprint/Waiver
Daycare license#_____________
Unified Court System Program code: _ - _ _ _ _ _ - _ _ _ - _
SCR
Daycare license#_____________ Occumed—Medical/PPD Program code: _ - _ _ _ _ _ - _ _ _ -
Choicepoint Program code: _ - _ _ _ _ _ - _ _ _ - _
SS#__________ DOB________ Addresss__________________________
Reason for all requested changes: (please be as specific as possible including names etc.)
Supervisor filling out form Signature_______________________________ Date_____________________________
Director’s Approval Signature____________________________________ Date_____________________________
For HR Department use only:
__________ Approved—Effective date ____________
__________ Denied
- Reason _____________________________________
HR Dept. Signature
__________________________________
Date:
__________________________________
** Form to be used for current Employee CHANGES or ADDITIONS
updated: 11/6/2012
Instructions for completing the Employee Status Change Request Form:
This form is to be completed only when there are changes to the current position of an existing employee.
ALL FORMS MUST BE FILLED OUT BY SUPERVISOR, FORWARDED TO DIRECTOR FOR
SIGNATURE AND APPROVAL, AND THEN APPROVED BY HR DEPT. PRIOR TO ANY
CHANGE FOR THE EMPLOYEE.
Please provide the following information on each Employee Status Change Request Form:
1. Enter the name of the employee
2. Enter the employee’s current work location
3. Enter the employee’s current position
4. Enter the name of the employee’s supervisor
5. Enter the breakdown (hours) in each program that the employee is currently being paid out of.
Under the following information under the changes/additions requested section:
Place a √ (check mark) on only the information that is being changed or added
1. If you are unsure as to work hours or weeks this information is available from your Director.
2. Add another position—this applies if employee has time to fill in for a medical absence, vacationing
employee or an employee on some type of leave.
3. Change in work hours—adding additional hours to job or subtracting from current work hours
4. Change in location—moving from one center to another i.e.: NHS to SHS (please use abbreviations)
5. Change in position—moving from one job position to a different position
6. Change in rate of pay—this changes because of position change only (you must verify amount with HR)
7. Effect time—this need to be specific so when duration is completed we can change back to original
status.
8. Enter the breakdown (hours) in each program that the employee is now to be paid out of.
9. Reason for change—please be as specific as possible and if needed please include all names that the
change will effect.
AFTER FORM IS COMPLETED PLEASE RETURN TO YOUR DIRECTOR—FORM CAN BE
FAXED OR EMAILED TO SPEED UP THE APPROVAL PROCESS.
DIRECTORS SIGNATURE REQUIRED THEN FAX TO H.R. DEPARTMENT FOR APPROVAL.
UPON RECEIPT OF APPROVAL/DENIAL YOU WILL BE INFORMED IMMEDIATELY AND
WILL THEN HAVE THE AUTHORITY TO PROCEED WITH YOUR CHANGE/ADDITION.
** Form to be used for current Employee CHANGES or ADDITIONS
updated: 11/6/2012

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