Concurrent Employment Information Form Page 2
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1
2Benefits Eligible
UNIVERSITY OF CENTRAL ARKANSAS
Appointment
Regular
PERSONNEL ACTION FORM
Change in Status
Extra Help
Termination
Emergency Hire
XXXXXXXXXXXXXX
NAME
Last
First
M.I.
SOCIAL SECURITY NUMBER
UCA ID
A1. PROPOSED STATUS
B1. PRESENT STATUS
1. College/Division
2. Primary Dept.
Name
3. Title of Position
4. Employment
Grade
Full-time
Part-time
Grade
Full-time
Part-time
Status
________
______%
________
______%
5. Salary
$
12 mo. ______
9 mo._______
$
12 mo. _____
9 mo._______
10 mo. ______
Other ______
10 mo. _____
Other ______
6. Academic Term
1 (Spring) ____ 3 (Summer I) ______ 5 (Other)____
1 (Spring) _____ 3 (Summer I) ______ 5 (Other)_____
Designation
2 (Fall)
____ 4 (Summer II) ______
2 (Fall)
_____ 4 (Summer II) _______
A2. PROPOSED SALARY DISTRIBUTION
7. Position
8. Salaries Account Number and Name
9. %
10. Effective Dates
11. Amount to be Paid
Number
(Leave Blank)
Account Number
Account Name
From
To
(Payroll Use Only)
B2. PRESENT SALARY DISTRIBUTION
7. Position
8. Salaries Account Number and Name
9. % 10. Effective Dates
11. Amount to be Paid
Number
Account Number
Account Name
From
To
(Payroll Use Only)
(Leave Blank)
C. EXPLANATION
1. Reason for the Appointment, Change, or Termination: __________________________________________________________________________________
_______________________________________________________________________________________________________________________
2. Person being replaced: ______________________________________
3. Is this a Tenure Track Position?
_______ Yes
________ No
4. For termination, show the last day the employee was or will be present for work: _________________________________________________________
SIGNATURES
Principal Investigator (Grants)
Date
HUMAN RESOURCES OFFICE ONLY
Hiring Unit/Department Chair
Date
Job Code: ________
Title Code: __________
Schedule: _________
Dean of College
Date
Date: _____________
Concurrent Approved:______________________
Vice President
Date
PAYROLL OFFICE ONLY
Human Resources
Date
Budget Office
Date
President
Date
Entered by: __________________
Date: ____________________
Please Submit This Form in Yellow
HR (11/10)
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Parent category: Business