Employee Status Change Form
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1Employee Status Change Form
Employee Name: ___________________________________________________ Social Security #: __________________________________
Address: ______________________________________________________________________________________________________________
DT #: ___________ Location Name: _________________________________ Position: ____________________________________________
Effective Date: ______/______/______
Date of Birth: ______/______/______ E-mail: ________________________________________
Employee Status
Type of Change:
New Hire
Rehire
Employee Status Change
Regular Full Time
(30 hours or more)
Hours per week: _________
Regular Part Time
(29 hours or less)
Hours per week: _________
Temporary
(Less than 6 months)
Hours per week: _________
On Call
(As Needed)
Salary Establishment/Change
Type of Change:
New Hire
Merit Increase
Promotion
Cost of Living
Other _______________________
New Pay Rate:
$__________________
per hour
Bi-weekly salary amount
Annual Salary $______________________
(Non-Exempt)
(Exempt)
(If Exempt)
IF SCHOOL EMPLOYEE: ( If contracted teacher, please attach a copy of the contract)
______/______/______
______/______/______
# of Pays: _____________
First Check Date:
Final Check Date:
Status Change
Location Change (Transfer)
From_______________________________ To ________________________________
Position Change
From_______________________________ To ________________________________
Leave of Absence
From_______________________________ To ________________________________
Other
_______________________________________________________________________
Termination of Employment
* Please complete a Work History Form for Pension if hired prior to 01/01/2007
Last Working Day: ______/______/______
Eligible for rehire?
Yes
No (if no, list reason) _______________________________________________________________
Select ONE reason for separation:
Voluntary:
Dissatisfied w/ job or company
Retirement
School
No Call/No Show
Better job/pay/benefits/hours
Medical-self or family
Relocating
Family issues
Other________________________________________________
Involuntary:
Poor performance
Gross Misconduct
Contract Ended
Unqualified for job
Violation of company policy/procedure
Unprofessional conduct
Other________________________________________________
Remarks:______________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Parish/School/Agency Signature:______________________________________________________________ Date:_______________________
Fax Original to Diocese of Tucson – HR Dept. (520) 838-2583 OR Email to
PRINT
HR Rec’d Date:_____/____/_____
IOI:____/____/_____
HRO:____/____/_____
BAS: ____/____/_____
REVISED: 05/01/15
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Parent category: Business