Employee Status Adjustment Form
Use when there's a change in Employee Status
Full Name of Employee with Adjustment in Status
First Name
Last Name
Date the Adjustment should take effect
-
Month
-
Day
Year
If day of - Call maybe required.
Current Title & Department
Indicated whether Ops or Admin
Currently Exempt / Non-Exempt
Exempt
Non-exempt
Current Employment Status
Full-time
Part-time
Current Wage
Hourly or Annual (please indicate)
Current Benefits
Language Stipend
Health Care Stipend
Other
Status/Wage Adjustment
New Employee Title & Department
Please indicate whether Ops or Admin
New Position
Exempt
Non-exempt
New Employment Status
Full-time
Part-time
Paid Administrative Leave
Non-paid Administrative Leave
Termination
New Wage, if applicable
Indicate whether hourly or annual
New Benefits, if applicable
Language
Health Care
Other, including Bonus
Change in Benefit amount
Indicate whether, OTO, per hour, per month, etc.
Write brief justification
Upload Signed Acknowledgement
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