Personnel Activity Report Template
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1Regional School District No. 17
Personnel Activity Form
___BOE ___Café ___Grants
Effective Date___________
Action: _____________________________________
(New hire, resignation, degree change, dock, address change etc…)
Social Security____________________
Name: __________________________________________________
Address: _________________________________________________________
Town: ____________________________State______ Zip____________
Telephone: __________________Birth Date_________________________
Bldg/Location: _______________ Position: ______________________________
Step/Grade______________________ Acct#___________________________
Circle one:
Full Time
Part Time
Annual Salary__________________ Hourly Rate ______________
Circle One: Non Union, Support Union, Custodian, Teacher, Admin
Authorized Signature_________________________________Date:_________________________
(Administrator taking action)
Dir. Fiscal Operations Signature _______________________ Date______________________
Superintendent’s Signature_______________________________Date______________________
Payroll Only:
Employee #
____________
Trb
Y/N
1% _____________
6%_________________
403b Acknowledgement Form dated _____________________
Medicare Y/N
SS
Y/N
If No, Social Security Form # SSA-1945 dated _______________
Benefits Y/N
Ins Group#____________Deduction:_________________
Date posted in system _______________________ by: ________________________
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Parent category: Business