Fillable Printable Sample Employee Status Change Form
Fillable Printable Sample Employee Status Change Form
Sample Employee Status Change Form
Employee Status Change Form
Employee Name: _____________ ________________ _______________ So ci al Security #: _____________________
Address: __________________________________________________________________________________________
Location: ___________________________________________ Posi ti on: ___________________________________
Effective Date: ______/______/______ Date of Bi r th : ______/______/______ E-mail: ___________________________
Em ployee Status
Type of Change: New Hire Rehire Employee Status Change
Regular Ful l Time ( 30 hours or more) Hour s per week: _________
Regular Par t Time ( 29 hours or less) Hour s per week: _________
Tempor ary ( Short Term) Hour s per week: _________
On Call ( As Needed)
Salary Establishment/Change
Type of Change: New Hire Merit Increase Promotion Other ___________________________
Cur rent Pay Rate: $____________________ per hour per year
New Pay Rat e: $____________________ per hour per year
Exem pt (Salaried) Non- Exempt ( Hourly)
Status Change
Loc ation Change (Transf er) Fr om_______________________________ To ________________________________
Positi on Change From_______________________________ To ________________________ ________
Leav e of Absence Fr om_______________________________ To ________________________________
Other _______________________________________________________________________
Termi nation of Employment * Please com p l ete a Work Hi story Form for Pensi o n
Last Work ing Day: ______/______/______
Eligible for rehire? Yes No (if no, list reas on) __________________________________ _____________________________
Sel ect ONE reason f or separation:
Voluntary :
Dissatisfied w/ job or company Retirement School No Ca l l/ N o Show B etter j ob/pay/ benefits/hours
Medical-self or family Relocating Fam i ly is s ue s Other________________________________________________
Involunta ry:
P oor perf or m ance Gr oss Misconduct At tendance/Tardiness Unqualif ied for j ob
V iolation of company policy/procedure Unpr ofessi onal conduct Other________________________________________________
Remarks:____________________________________________________________________________________________________
____________________________________________________________________________________________________________
Parish/Schoo l/Agency Signature:_______________________ ________________________________ Date:_______________________
Fax Original to Diocese of Tucson – HR Dept. (520) 838-2583
Revised: 06/22/2010
