Fillable Luzerne County Employee Change Of Status Form printable pdf download

Date Submitted________________

Appendix I‐1A

LUZERNE COUNTY EMPLOYEE CHANGE OF STATUS FORM

HUMAN RESOURCES INFORMATION

 New Employee

 Existing Employee

 Elected Official

Name_____________________________ Employee Number______________ Effective Date______________

Job Title___________________________ Department_______________________________________________

(Complete for New Employees Only)

Select 1

Regular Temporary Seasonal Per Diem //  Full Time Part Time // Union Non‐Union // Exempt Non‐Exempt

Elected Official

Address_________________________________ City______________________ Zip__________ State________

Telephone #____________________ SS#_______________________

Race (for EEOC purposes only):  White  Black  Hispanic  Asian  Other

Annual Salary _____________ Hourly Rate__________ Bi‐weekly Hours_________ Date of Hire__________________

(Complete for Existing Employees Only)

CATEGORY OF CHANGE

(Check all changes that apply and complete “From/To” Section below):

Position Title Hours of Work Transfer Exempt/Non‐Exempt Salary/Wages Promotion

Demotion Suspension Health Care Deduction

Termination ( __Voluntary Resignation __Retirement __Layoff __w/cause __w/o cause)

Leave of Absence ( __with pay __without pay // From _____________ To ______________)

(__FMLA __Intermittent __Military __Worker’s Comp. __Personal Leave)

Personal Info ( __Name __Address __Phone __Municipality Code)

Other __________________________________________________________________________________________

FROM

___________________________________________

_____________________________________________

___________________________________________

_____________________________________________

___________________________________________

_____________________________________________

Explanation of Change:______________________________________________________________________________

_________________________________________________________________________________________________

AUTHORIZATION (Per Authorization Schedule)

Payroll Clerk ________________________________________________________________ Date__________________

Department Manager__________________________________________________________ Date__________________

Human Resources Director______________________________________________________ Date__________________

County Manager______________________________________________________________ Date__________________

Luzerne County Employee Change Of Status Form