Employee Status Form

CIS-HOT Employee Status Form
Employee Full Name
Effective Date

MonthDayYear
Date
Check Applicable

New Hire (A,B,C,D,E-see NOTE)Position/Coding Change (A,C,D)Rehire (A,B,C,D)New/Change Contact Info (B,C)Interim Position (A,C,D,E-see NOTE)Salary/Pay Change (A,C,E)Temporary Position (A,B,C,D,E see NOTE)
Other reasons to submit a status form:
1. Changing departments
2. Moving campuses
3. Changing supervisors
4. Pay change
5. Funding source/percentage change
6. Title change
NOTE: If any of the following conditions exist, CEO approval is required prior to taking action:
1. Any newly created position
2. Salary Change for any employee
3. Any change with a Coordinator that requires authorization
SECTION A: Employment Information
New (Complete all)Change (Complete applicable portions only)
Job Title
Supervisor
Work Site
FLSA Status

ExemptNon Exempt
PT/FT Status

Full Time (40hrs/wk)Part Time
If Part-time:

< 30hrs/wk30hrs/wk or more
CODING
Grant Codes Reference:

6001 – Wages – M&G
6010 – Wages – Program Director & Coordinator
6016 – Wages – Data Entry Clerk
6020 – Wages – Site Coordinator
6024 – Wages – Youth Development Specialist
6025 – Wages – Career Development Coaches
6030 – Wages – Case Managers (CYD)
6050 – Wages – Contra (PTO)
Box1: Line Item Code (4 digits)
Box 2: Line Item Code (4 digits)
#1 Grant
#1 - % to Grant
See supervisor for this percentage.
#2 Grant
#2 - % to Grant
See supervisor for this percentage.
PAY RATE
Annual Salary
Hourly Salary
Temp/Interim Pay Only: Amount per month
Temp/Interim Pay Only: Begin/End Dates
Begin Date

MonthDayYear
Date
End Date

MonthDayYear
Date
SECTION B: Contact Information
New (Complete all )Change (Complete applicable portions only)
Home Address
City/State/Zip
Permanent Address (if different than home)
City/State/Zip
Home Phone
Cell Phone
Emergency Contact Information #1
Name
Relationship
Phone
Emergency Contact Information #2
Name
Relationship
Phone
SECTION C: Employee/Supervisor Authorization
Supervisor Full Name
Supervisor Signature
Date

MonthDayYear
Date
SECTION D: Chief Officer Authorization
Chief Officer Full Name
Chief Officer Signature
Date

MonthDayYear
Date
SECTION E: Chief Executive Officer Authorization
Chief Executive Officer Full Name
Chief Executive Officer Signature
Date

MonthDayYear
Date
Should be Empty:

CIS-HOT Employee Status Form

SECTION A: Employment Information

CODING

PAY RATE

SECTION B: Contact Information

SECTION C: Employee/Supervisor Authorization

SECTION D: Chief Officer Authorization

SECTION E: Chief Executive Officer Authorization