Personnel Action Form
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1PERSONNEL ACTION FORM
To be used for employees with a permanent PCN or Irregular Help employees on benefits
Use Temporary and Adjunct/Non-Credit Course PA for temporary employees and adjuncts (non LCSC employees) teaching non-credit courses
Use Adjunct Faculty/Credit PA for adjuncts (non LCSC employees) teaching courses for credit
Today’s Date
Name
SSN
Effective Dates
XXX-XX-
Begin Date
Address*
End Date
*New hire only
Check All That Apply
New Hire
Payment in Addition
Replacement PA - Original Dated__________
(#10 & possibly #12)
(#11)
Contingent upon Grant Funding
Payment in Addition/Adjunct Instruction
Separation - Last Day Worked ____________
(#15)
Title Change
Leave of Absence with Pay
(#11)
(#11&12)
Salary Change
Leave of Absence without Pay
(#11)
(#11&12)
Budget Code Change
Sabbatical
)
(#11)
(#12
NEW HIRE or CHANGE TO (complete all information)
SEPARATION or CHANGE FROM (only complete what has changed)
1. PCN
1. PCN
2. Title
2. Title
3. Department
3. Department
If less than 1.00, complete #13 & attach
If less than 1.00, complete #13 & attach
4. FTE
____
Non-Working Hours Schedule
4. FTE
____
Non-Working Hours Schedule
Hired during contract period
Hired during contract period
5. Salary
Budget Office to prorate salary
5. Salary
Budget Office to prorate salary
Hourly Rate
Hourly Rate
6. Classification
6. Classification
7. Tenure Status
7. Tenure Status
8. Health Benefits
Yes
No
8. Health Benefits
Yes
No
9. Budget Code/%
__-__-______
____ % (whole percent only)
9. Budget Code/%
__-__-______
____ % (whole percent only)
Budget Code/%
__-__-______
____ % (whole percent only)
Budget Code/%
__-__-______
____ % (whole percent only)
100
Budget Code/%
__-__-______
____ % (whole percent only)
Budget Code/%
__-__-______
____ % (whole percent only)
Budget Code/%
__-__-______
____ % (whole percent only)
Budget Code/%
__-__-______
____ % (whole percent only)
10. New Position:
Yes
(Forward New Position Approval Form with PA)
No - Replacing ____________________________
FOR BUDGET OFFICE USE ONLY
Classified Staff - Register # ___________________
Object Code
a. Shift Differential Eligible - Yes
No
Adjusted Contract/Contract Payoff
11. Comments (reason for changes, payment in addition, etc.)
Adjusted Hourly Rate
FOR HUMAN RESOURCE SERVICES USE ONLY
Old Rate
Old PCN
New Rate
New PCN
12. Comments/Special Notations for Contract
Pay Date
Type of Time
Hours/Payment
ACA Hours
13. FTE Change/Hours per Week/Total Class Hours Taught/Comments
14. Payment Schedule (payment in addition)
15. Academic Affairs Payment in Addition for Instruction (complete separate PA for each semester)
Semester
Adjunct
Replacement Cost
Replacement
Subject Course Sec. Cr.
$/Credit #/Stdnts
Total
Last Name
)
(charged to adjunct line)
(charged to a salary line
$0.00
1
Salary
PCN
Last Name
Reason
$0.00
1
Fringe
$0.00
0
$0.00
Total Credits
Total Amount
Total
Salary
Fringe
$0.00
Total
Routing/Approval
(date and approval signature stamp)
Coordinator/Dept.
Grant Monitor
Vice President/
Human Resource
Dean
Budget Office
Head/Director
(if grant funded)
President
Services
Originator: __________________________________________
Revised 01/2016
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Parent category: Business