Personnel Change Request
Employee Name
*
Today’s Date
*
/
Month
/
Day
Year
Effective Date
*
/
Month
/
Day
Year
Name of Person Completing Form
*
Salary Change
Merit Increase
Reduction in Pay
Other Change of Pay Rate
Change in GL Account
Change of FTE
Voluntary Separation
Involuntary Separation
Retirement
Probation
End Probation with Merit
End Probation (Transfers)
Extend Probation
Termination
Voluntary Separation
Involuntary Separation
Retirement
Comment/Explanation
Updated Employee Information
Department
Job Class Title
Position Number
GL Account Number
Supervisor
Status
Regular
Full Time
Temporary
Part Time
On Call
Management/Non-Rep
Grade
*
Step
N/A
Hourly Rate
*
Top of Range
Incentives
Type
Percentage
Dollar
Add
Remove
Type
Percentage
Dollar
Add
Remove
HR Use Only
New Hire
Rehire
Promotion
Transfer
Reclassification
Demotion
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