EMPLOYEE CHANGE OF STATUS REPORT

EMPLOYEE CHANGE OF STATUS REPORT

Must be filled out by authorized office staff.
Employee*

First NameMiddle NameLast Name
Last 4 of SN
Report Submitted By:*

First NameMiddle NameLast Name
Reporting Employee Phone Number*

Area CodePhone Number
Date of Report*

MonthDayYear
Date
CHANGE OF EMPLOYMENT STATUS FROM:*
BEFORE CHANGE
CHANGE OF EMPLOYMENT STATUS TO:*
AFTER CHANGE
EFFECTIVE DATE OF CHANGE*

MonthDayYear
Date
Terminations must be cleared by Managment and HR Dept.

Suspensions must have reason for suspension and conditions or length detailed in the suspension
Reason for change of status - Narrative*
INCLUDE ALL DETAILS LEADING UP TO TERMINATION, SUSPENSION, RESTRICTIONS, ETC
For Voluntary Quits:*

Notified appropriate staff, 2 week noticeNotified appropriate staff, less than 2 week noticeDid not notify appropriate staff, no notice given.NOT APPLICABLEOther
How was the employee notifed of change of status*

By emailBy phoneBy letter/mailIn PersonOther
Summary of Employee's Notification*
Include all methods used to notify EMPLOYEE, and any methods EMPLOYEE acknowledged or Notified managment.
Will the employee be eligible for rehire in the future*

YesNoOther
Name of Manager or HR who approved change in status*
Termination may only be authorized by manager. Suspensions may be authorized by supervisors. Being sent home will be noted in spot report if it does not immediately lead to a suspension or termination.
Have you notified payroll department regarding change of status? This form may not be filled out until payroll was notified.*

YesNoOther
Should be Empty: