Personnel Action Form

Effective Date:*

Employee Number:*

Full Name*

First NameLast Name

Location:

Enter only if location is changing

Current Position Title:

Enter only if title is changing

FTE

Current Department:

Enter only if team/dept is changing

Current hours per week

Enter only if hours are changing

Current Supervisor:

Enter only if supervisor is changing

Differential:

LanguageOther

Differential Amount:

Current Salary:

Enter only if salary is changing

Performance Metrics(PFTE):

Enter only if PFTE is changing

Additional Changes or Details:

New hours per week*

New FTE

New PFTE:*

New Position Title:*

Does this position require centralized scheduling?

YesNo

Is this position title change due to the acquisition of a new license?

Yes; Clinical(LPC, LMFT, LCSW, or Psychologist)Yes; SUD(CAC II, CAC III, or LAC)No; title change only. License has been in place and in good standing.Other

New location*

New Supervisor*

New Department:

New Salary:*

Submitted by:*

Your First & Last Name

Email address of individual submitting request*

Supervisor or individual submitting this PAF

Once the form has been completed, please enter the Director or VP name to approve, as well as their email address (below) and submit the request. You will receive a copy of the form via email and your department Director or area VP will receive a copy with the option to "edit the form", where they can electronically sign and resubmit.

Approver First & Last Name:*

Director,VP, or Officer approval

Approver Email Address:*

abc.123@aspenpointe.org

Approval Signature:

Director, VP, or Officer E-Signature

For HR Use Only:

□ Signed job description
□ Licensure Copy
□ Credentialing approval
□ Exempt/Non-Exempt change
□ Assign/transfer direct reports
□ Benefit eligibility change

Tamera.Parkins@aspenpointe.org