Mt. San Antonio College Employee Change Of Status Form
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1MT. SAN ANTONIO COLLEGE
EMPLOYEE CHANGE OF STATUS
Employee Name:
BANNER ID:
Effective Date of Change:
*Effective End Date:
☐Classified
☐Confidential ☐Faculty ☐Supervisory ☐Manager
TYPE OF ACTION(S)
FROM
TO
☐ PERMANENT CHANGE(S)
Job Title:
Job Title:
Department:
Department:
☐ Account Number
☐ Departmental Change
Account No:
Account No:
☐ Hours
Percentage:
Percentage:
☐ Months
Account No:
Account No:
☐ Promotion
Percentage:
Percentage:
☐ Reclassification
☐ Shift Change
Total Hours/Week:
Total Hours/Week:
☐ Add Shift Differential
Number of Months:
Number of Months:
☐ Remove Shift Differential
Days of Week:
Days of Week:
Shift Hours:
Shift Hours:
☐ Other
☐ SEPARATION
BUDGET USE ONLY
BUDGET USE ONLY
☐ Dismissal
Position No.: __________________
Position No.: __________________
☐ End of Assignment
Contract No.: __________________
Contract No.: __________________
☐ Lay Off
☐ Resignation
HUMAN RESOURCES USE ONLY
HUMAN RESOURCES USE ONLY
☐ Retirement
Range: Step: __________________
Range: Step: __________________
☐ Other
Longevity:
__________________
Longevity:
__________________
☐ TEMPORARY CHANGE(S)
☐ Additional Assignment
Differential: __________________
Differential:
__________________
(P/T Classified Employees)
Job FTE:
__________________
Job FTE:
__________________
☐ Administrative Leave
Pay Rate:
$_________________
Pay Rate:
$_________________
☐ Change of hours/months
☐ Percentage of Full-Time
EXPLANATION OF CHANGE
:
(attach additional documentation if necessary)
☐ Increase from
to
☐ Decrease from
to
☐ Substitute/Interim (Out-of-Class)
☐ Other
___________________________________________
__________________
Manager (Print name and sign)
Date
________________________________ _____________
_____________________________
_____________
V.P.,
Signature
Date
V.P., Human Resources Signature
Date
________________________________ _____________
_____________________________
_____________
Assoc. V.P., Fiscal Services Signature
Date
President/CEO Signature
Date
SEND ORIGINAL TO HUMAN RESOURCES
*Temporary Assignments MUST have a projected end date (no greater than the end of the fiscal year). A new form must be submitted to the Office
of Human Resources every fiscal year and MUST be Board Approved PRIOR to changing the employee’s status.
Employee should not work in requested assignment until after Board Approval.
HUMAN RESOURCES USE ONLY
☐ Denied
☐ Banner
____________________________________
_____________________
____________________
☐ Approved
☐ Payroll
Human Resources Signature
Date
Board Date
**Reviewed by President’s Cabinet on:
_______________________
h:\hrs\forms\EEStatusReportJan13.docx nu
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