Personnel Action Form-LOA/Suspension/Termination

Personnel Action Form

For LOAs, Suspensions, or Terminations (Voluntary or Involuntary)
Store Number*
Enter TM's current 4 digit store # (Office/Support: use 9999)
DM Area:*
EE ID: (HR Use)
Team Member's Name*

TM First NameTM Last Name
Last 4 digits of SSN:*
TM's Current Position: (as listed in HR system)*
Change Type:*

LOA (Start)SuspensionTermination
Effective Date:*

MonthDayYear
Date
LOA Reason:
Expected LOA Return Date:

MonthDayYear
Date
Termination Reason:
List Policy Violation(s) resulting in Involuntary Termination:
Unprofessional Conduct, Theft, Attendance/Scheduling, Drivosity, etc
Did you receive HR approval for Involuntary Termination?

YesNo
List the last 2+ consecutive dates of no call/no shows:
Rehire Status:
Termination Details and/or Reason for Rehire Status selected:
Explanation/Reason for requested LOA or Suspension:
Supporting Doc Upload (optional):

Cancelof
Submitted By:*

Mgmt First NameMgmt Last Name
Mgmt Position:*
Enter your MAC Pizza email (for confirmation of form submission)*
mac1234@macpizza.net
Date/Time Submitted

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty: