Human Resources Payroll and Status Change Form

Camille Smilen, MHRM, BSW, Human Resources Manager | Christephania Lee, Recruiting/Onboarding Specialist | Dezirae Paschal, SHRM-CP, HR Specialist

Copies: Original: Employee File | Employee / Payroll
Human Resources Payroll & Status Change Form
Date Completing Form:

MonthDayYear
Date
Employee Name:

FirstLast
Employee ID:
Department:
Before Change:
After Change:
Department:
After Change:
Department:
Before Change:
After Change:
RU Number 1:
Before Change:
After Change
RU Number 2:

(If employee is allocated across multiple RUs)
Before Change:
After Change
RU Number 3:

(If employee is allocated across multiple RUs)
Before Change:
After Change
FTE Number:
Before Change:
After Change:
Category:
Before Change:
After Change:
Classification:
Before Change
After Change
Status:
Before Change:
After Change:
Original Date of Hire:
MonthDayYear
Job Title:
Before Change:
After Change:
Replaces:
Before Change:
After Change:
Supervises Others:
Before Change:
After Change:
Salary/Hourly Rate:
Before Change:
After Change:
Supervisor:
Before Change:
After Change:
Effective Date of Change:
Attention Supervisor: You must attach supporting documenation, like the interview packet.
Upload Attachments:

Cancelof
Supervisor Signature: *
By typing my signature, I confirm that I completed this form and am responsible for its accuracy.
Effective Date*

MonthDayYear
Date
Comments:
Person completing form:

First NameLast Name
Title:
Date

MonthDayYear
Date
HR USE ONLY
ResignationTerminationLayoffDeath
Effective Date of Separation:

MonthDayYear
Date
Last Paid Date:

MonthDayYear
Date
YesNo
Effective Date:

MonthDayYear
Date
Ending Date:

MonthDayYear
Date
Date of Death:

MonthDayYear
Date
Time of Death:
YesNo
Leave:
Effective Date:

MonthDayYear
Date
Ending Date:

MonthDayYear
Date
YesNo
Received by Human Resources:
HR Staff:

Clear
Camille Smilen, MHRM, BSW, Human Resources Manager Brandi Sines, HRG Dezirae Paschal, SHRM-CP
Date:

MonthDayYear
Date
Final Approval:
Approved by:

Clear
William Wims, Chief Executive Officer
Date:

MonthDayYear
Date
Should be Empty:

Human Resources Payroll & Status Change Form

Department:

Department:

Department: