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Employee Status Change Form
M#
Name:
Last
First
MI
Dept. Name:
Org#:
Contact Person:
Phone #:
Employee’s primary position is: faculty/academic OR staff (non-union) OR staff (unionized)
Immigration authorization needed: Yes No
Supervisor’s Name ____________________________
REASON(S) FOR STATUS CHANGE
(Check all that apply) * Supporting Documentation Required
(click here)
Academic Appointment (for current staff)*
Promotion* (staff only)
Title Change*
Additional Compensation/Appointment
Rate Change*
Other*
(complete below & pg 2)*
Administrative Appointment
Reorganization*
(for faculty)*
Change in FTE*
Return 9/10 Month (for staff)
Change of Supervisor*
Summer Research or Other Sponsored Activities
Dept/Job Transfer*
Summer Teaching
Extend End Date to ___________________*
Course(s) # & # of Credits
/
Leave of Absence/Change in Leave Date (not sabbatical)*
Termination*
(includes layoff, retirement, resignation, etc.)
Type of Leave
Time Entry Method:
Web Time
Dept Time
Manual(paper)
Time Sheet Org #: _________________
With pay
Without pay
TS Approver POSN#: ____________ Approver Name:_____________________
Comments/Justification:
Will the work location be in Michigan?
Yes
No
If no, where will the work take place?
EFFECTS OF CHANGE/NEW INFORMATION (required)
Start/Effective Date (MM/DD/YYYY)
______/______/______
End Date
______/______/______
Compensation Amount
$
(if lump sum; required when applicable)
Index(es)
Account Code(s)
(If multiple indexes, state %)
FOR THE FOLLOWING SECTION, COMPLETE ONLY INFORMATION THAT IS CHANGING (below and on side 2).
Present Status
Change to
Add to Present Status
Dept Name &
Dept Name
Org#
Dept Name
Org#
Org#
< 9 mo 9 mo 9/10 mo 12 month
< 9 mo 9 mo 9/10 mo 12 month
Service Basis
Other ____________
Other ____________
FTE % effort
____ %Fall ____ %Spring ____ % Summer ____ Annual
____ %Fall ____ %Spring ____ % Summer ____ Annual
Supervisor
Rank
Discipline
Administrative Title
Tenure Basis
Tenured
Tenure-Track Non-Tenure-Track
Tenured
Tenure-Track Non-Tenure-Track
9 month Full-time Base Salary: $________________
9 month Full-time Base Salary: $_________________
Compensation
Actual Salary:
$________________
Actual Salary:
$_________________
Title
$____________ [
$____________ [
Compensation
yearly salary (exempt staff)]
yearly salary (exempt staff)]
Compensation
$____________ [
$____________ [
hourly rate (non-exempt staff)]
hourly rate (non-exempt staff)]
(includes non-exempt, UAW,
AFSCME, POA)