Headcount & Resignation Request Form

Please utilize this form to request HC (headcount), either replacement or addition to staff. In addition will drive the following:

standardized approach
one platform to track HC requests and approvals
trend 'replacements' vs. 'additions' by locations and positions
actual vs. budget

Employee/Labor costs directly impact the bottom line - we need to ensure we are maximizing and driving productivity as best as we can through process improvements, scheduling efficiencies, etc.

Once position is approved, Regional Manager or HR will notify you of approval. Please proceed with posting job, etc. HR will track open requisitions on a spreadsheet for all open positions.

Office Location

Regional Manager

Manager requesting HC

First NameLast Name

Email

example@example.com

Position requesting

Please enter position, if not listed above

How many FTE's are currently in this budget?*

Is this role for 2025 or 2026 budget?*

Have you looked at the budget to validate that this replacement or addition is in the FTE budget?*

You must review the budget with RM prior to approval. If the answer is no then the position will not be approved.

Position type (ex: full-time/part-time)

Is position budgeted? *

If unsure please work with your Regional Manager to confirm before submitting. If the answer is 'no' we will not proceed with posting the position.

Please specify the month in which this requisition is being requested in relation to the budgeted headcount*

The purpose of this ask is to provide additional context or justification for the timing of this requisition related to budgeting considerations, such as resource needs, or operational requirements.

Confidential Search

If we need to search to replace an individual that is not aware that we are going to replace them

Was position on hold due to COVID-19?*

Replacement of StaffAddition to StaffNew PositionOther

If replacement, please enter name of employee resigning

If replacement, please enter hourly rate of person in role currently ($)

Is person leaving involuntary or voluntary?

Is this person a high performer? Someone the doctor really relies on?*

Why did employee cite leaving?*

Is this someone we want to retain?

If you'd like to retain please contact your HR Generalist and Regional Manager

If replacement, what is the date employee is leaving?

If replacement, why is person leaving?*

Please make sure you send employee exit survey link: https://www.surveymonkey.com/r/Riccobeneexitsurvey

Have we tried to retain this person, if person is someone we want to keep? (Please provide details if applicable). This will help HR/Recruiting team understand turnover.*

If we want to keep person, discuss with Regional Manager options.

What is the work schedule you are looking for this position (ex: 5 days, normal hours or 4/10's (7AM-6PM, M-Thursday)*

What is skill set of person leaving? (ex: implants, invisalign, etc.)*

x-raynitrouscoronal polishingOther

If Dental Assistant, is your Doctor willing to train?*

Have you talked to your doctor about willingness to train if we hire right attitude, etc.

What would you think would be a good culture fit?*

(ex: bubbly vs. quiet, etc.)

If replacement, please input employee's current pay rate

Hourly rate/salary range requested ($)

Please provide as much detail below per your metrics selection:

Please provide level of detail below regarding current staffing levels:*

Rows	Doctors (# of docs each day)	Dental Assistants	Dental Hygienists	Patient Coordinators	Sterilization Techs	Insurance Coordinators	Collections Coordinators
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
[other items to note]

What work will be in jeopardy if position is not filled? (Be Specific)

Why won't re-purposing existing headcount work?*

NEW POSITION ONLY. Please elaborate in detail what this new position would be doing (ex: job duties, skills, responsibilities)?

NEW POSITION ONLY. Please elaborate what success looks like for this position? What metrics would you be using to measure success.

Please upload any additional information

Browse Files

High priority (needed immediately, impacting patients seen)Medium priority (there are current work arounds with current staffing to make it work until right candidate is located)Low priority (future need - adding a doctor, or confidential future planning, etc.)

Comments

HEADCOUNT REQUEST FORM

REPLACEMENT INFORMATION