Employee Status Change Request Form
ADVERTISEMENT
1
2Employee Status Change
Request Form
To be completed by Supervisor. Submission of this request does not give Supervisor authority to make any
changes. Supervisor must wait for response from HR Department.
Employee: __________________________________________
Currently paid out of: (program, code, %)
Program
Code
%
________
_________
______
Current Work Location:________________________________
________
_________
______
Current position:_____________________________________
________
_________
______
Employees Current ADP Supervisor:___________________
________
_________
______
Changes/additions requested
_____ Additional work hours
from ___________ to ___________
To be paid out of: (program, code, %)
_____ Add another position in addition to current _________________________
________
_________
______
________
_________
______
_____ Change in work hours
from ___________ to ___________
________
_________
______
_____ Change in work weeks/yr
from ___________ to ___________
________
_________
______
_____ Change in location
from ___________ to ___________
________
_________
______
_____ Change in position
from ___________ to ___________
________
_________
______
_____ Change in rate of pay
from ___________ to ___________
________
_________
______
Effective date of change: __________________________________
Employees New ADP Supervisor
Information to be entered into ADP:
_______________________________________
Specific Daily Hours for position: M____________T____________W____________Th____________F____________
Clearance(s) needed: (circle appropriate)
Fingerprint/Waiver
Daycare license#_____________
Unified Court System Program code: _ - _ _ _ _ _ - _ _ _ - _
SCR
Daycare license#_____________ Occumed—Medical/PPD Program code: _ - _ _ _ _ _ - _ _ _ -
Choicepoint Program code: _ - _ _ _ _ _ - _ _ _ - _
SS#__________ DOB________ Addresss__________________________
Reason for all requested changes: (please be as specific as possible including names etc.)
Supervisor filling out form Signature_______________________________ Date_____________________________
Director’s Approval Signature____________________________________ Date_____________________________
For HR Department use only:
__________ Approved—Effective date ____________
__________ Denied
- Reason _____________________________________
HR Dept. Signature
__________________________________
Date:
__________________________________
** Form to be used for current Employee CHANGES or ADDITIONS
updated: 11/6/2012
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business