EmailMe Form - FP - Personnel Change Form

GENERAL INFORMATION

Employee Name *

First Last

Effective Date of Change *

MM / DD / YYYY

Division *

Current Location *

District Manager *

Type of Change

Please see the descriptions of the types of personnel changes and select the change you wish to capture in this form from the drop down menu.

Select from the following types of changes: *

PERSONAL DATA CHANGE

Please indicate which of the following information has changed (please select all that apply), then fill in the new information below.

Primary Phone

Cell Phone

Emergency Number

Email

Address

Marital Status and/or Name Change

Primary Phone

### - ### - ####

Cell Phone

### - ### - ####

Emergency Number:

### - ### - ####

Email Address

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Marital Status and/or Name Change

(If yes, forward a copy of legal documentation to back-up this change to HR)

If change in marital status or name, please explain below:

REHIRES

For rehires that have been separated from the company for 3 months or less. Please fill in any applicable information that has changed since separation. Also ask if direct deposit or federal withholding information has changed.

Personal Information

Marital Status

Only if it has changed

Primary Phone

### - ### - ####

Only if it has changed

Cell Phone

### - ### - ####

Only if it has changed

Emergency Contact

Only if it has changed

Email Address:

Only if it has changed

Emergency Phone

### - ### - ####

Only if it has changed

Address (Only if it has changed)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Position Information

Position:

Other Position:

use only if person will have more than one position.

Worker Category

Classification

Rate of Pay ($):

Per

TERMINATIONS AND LAYOFFS

Please select the reason for the change form below and use the drop down list(s) to define the change

Type of Termination *

Eligible for Rehire? *

Reason for Termination *

Last Day Worked

MM / DD / YYYY

If different from effective date

TIME AWAY FROM WORK- HR Use ONLY

Notify HR right away of any leave that exceeds 3 days.

Leave of Absence Reason *

Payout available time?

Expected Return Date

MM / DD / YYYY

EMPLOYEE DATA CHANGE

Please select from the following types of changes. Check off and complete ALL the fields that apply to the change.

Position Change

Division Change

Rate Change

Location Change

Schedule Change (Hours)

Sub Location Change

(Actual Individual School Name)

Position Change Information

Current Position: *

New Position: *

Division Change Information

Current Division:

New Division:

Rate Change Information- Current

Current Pay Rate ($)

Per

Rate Change Information- New

New Pay Rate ($)

Per

Pay Change Reason *

*Make sure to select and change ALL data that affects the employee (i.e. Position, Division, Location or Schedule changes associated to they pay increase or decrease)

If employee is receiving an increase for "General Increase / Decrease", please explain why:

Location Change Information

Current Location (G/L Code): *

New Location (G/L Code): *

Sub Location Change Information

Please indicate the full name of the school.

ie: ABC Middle School

Current School *

New School *

Schedule Change Information

Current # of hours per day:

Current # of days per week

New # of hours per day:

New # of days per week

Start Time

AM/PM

End Time

AM/PM

TECHNOLOGY

Accessibility of Databases (i.e. Email, ADP etc.)

Is technology change required?

NOTE: This step is NOT necessary for hourly, non-exempt level employees. *

Yes

No

Which Action is Needed? *

Delete Access

Grant Access

Modify Access

Office 365 (Email) *

Yes

No

If required check"yes" and proceed to the Office 365 Link by clicking the Office 365 Form Button

Additional Information and Comments

Please use the space below for any additional information you feel should be included in this form.

ACKNOWLEDGEMENT

I hereby certify that the information provided on this form is true and correct to the best of my knowledge. In addition, I understand that by entering my name on the line below I am digitally signing this form.

Name *

Position *

Email Address: *

(Email address of individual submitting this form is required for verfication purposes.)

Today's Date *

MM / DD / YYYY

BELOW THIS LINE FOR INTERNAL OFFICE USE ONLY

Unique ID