Position and Personnel Action Form
Check All that Apply:
☐ Classification
Leave of Absence
☐Employment
☐Leave of Absence
Employment
Interim Salary Adjustment (Begin)
☐ Benefits ☐ w/o Benefits
Leave Type
& Compensation
☐ Leave Type
I
Effective Date: _____________ End Date:___________
REASON FOR ACTION
Last Day Worked:
☐Faculty
☐Separation
Adjunct
Separation
☐Change of Status
Status Change
Effective Date: __________ Last Day Worked: __________
☐Other
Other
II
__________________________________________________________________________
PERSONAL
Banner ID
First
Middle
Last
INFORMATION
Hire Date/Contract Date_______________
Contract End Date (if applicable)_____________
Current
Banner
Supervisor & Position #
Dept./College/School
Position Title/Rank
Position #
(6-digits)
III
CLASSIFICATION/
Requested
Banner
Supervisor & Position #
Dept./College/School
APPOINTMENT TYPE
Position Title/Rank
Position #
(6-digits)
Classification Type
--Select--
--Select--
Appointment Type
--Select--
--Select--
☐ FT ☐ PT
☐FLSA Designation
FLSA Designation
IV
--Select--
☐No. of Months Current: ______ Requested:______
ASSIGNMENT STATUS
Leave Accrual: ________
--Select--
☐No. of Weeks: _____ ☐No. of Hours: _____ ☐FTE Change: ____ Eligible Benefits:________
Compensation:
Effective Date:
Current Amount:
Recommended Amount:
% of Increase
____________
$_________________
$_________________
_____________
NaN
Salary Adjustment Form is
required for all salary
increases 15% or more for
V
EHRA
Frequency:
SALARY INFORMATION/
☐Hourly
☐Monthly
☐One-Time Payment
☐Annual
BUDGET
--Select--
Installments ____
FOAP # Charged:
Fund__________/Org___________/Account____________/Prgm____________
________%
Fund__________/Org___________/Account____________/Prgm____________
________%
Fund__________/Org___________/Account____________/Prgm____________
________%
VI
JUSTIFICATION OR
COMMENTS
Signature
Date
Department Supervisor or Department Chair
Appropriate Vice Chancellor or Dean
VII
APPROVAL
Provost and Sr. VC for Academic Affairs
(Signatures are not required
Title III Office
if Hiring Proposal completed
Budget or Contracts and Grants Office
in PeopleAdmin System)
Chancellor (if applicable)
Legal Affairs (if applicable)
Employee
Date
Signatures
HR Representative
Date
Human Resources/Revised April 2016