Form C1045 - Classified Personnel Request For Change In Assignment Location, Basis, Shift, Status, Class, And/or Time Form

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Los Angeles Community College District

Personnel Commission

770 Wilshire Boulevard

Los Angeles, California 90017

CLASSIFIED PERSONNEL REQUEST FOR CHANGE IN

ASSIGNMENT LOCATION, BASIS, SHIFT, STATUS, CLASS, AND/OR TIME

_____________________________________________________________________________________________

___________________________________

LAST NAME

FIRST NAME

MIDDLE NAME

EMPLOYEE PERSONNEL NUMBER

_____________________________________________________________________________________________

___________________________________

HOME ADDRESS

CITY

ZIP CODE

HOME TELEPHONE NUMBER

____________________________________________________________________________________________

___________________________________

PRESENT JOB TITLE

PRESENT LOCATION AND DEPARTMENT

BUSINESS TELEPHONE NUMBER

____________________________________________________________________________________________________________________________________

Please answer the following questions about your

PRESENT REGULAR

POSITION:

Type of assignment (PSA): __________ 12 months (“A” basis)

__________ 10 months (“C” basis)

__________ Other: __________ Basis

Shift:

__________ Day (“A”) __________ Evening (“B”) __________ Night (“C”)

Hours per week:

__________________________

I HEREBY REQUEST A:

INTERESTED IN A TEMPORARY ASSIGNMENT?

(check type of action requested)

(indicate your response below)

CHANGE OF LOCATION

Location Requested:

(Check off your requested choice(s) below)

Yes

DO VDK

CHANGE OF

List units or offices preferred:

DEPARTMENT/OFFICE AT

1:_________________ 2. _________________ 3._______________

Yes

PRESENT LOCATION

All:

CHANGE IN SHIFT

Shift Requested: ( ) Day

(“A”)

( ) Evening

(“B”)

Yes

( ) Night

(“C”)

CHANGE IN SHIFT

Shift Requested: ( ) Early Day

( ) Late Day

Custodians Only

( ) Early Evening

( ) Late Evening

Yes

CHANGE IN BASIS (PSA)

Basis Requested: ( ) 12 month

(“A”)

( ) 10 months

(“C”)

Yes

( ) Other:

Specify:

CHANGE IN TIME

Time Requested: ( ) Full-Time

( ) Part-Time

Yes

Hours per week_______

CHANGE IN STATUS

This pertains to employees who are requesting a permanent change from a

regular to a limited-term assignment.

RETURN TO FORMER CLASS

Class Requested:____________________________________________

Yes

Indicate: Basis (PSA): ____

Shift:____

Time:_____

Status (ESG):_______

VOLUNTARY DEMOTION

Class Requested: ____________________________________________

Yes

Indicate: Basis (PSA):____

Shift:____

Time:_____

Status (ESG):_______

CHANGE TO A RELATED

CLASS IN WHICH I HAVE

Class Requested:_____________________________________________

NOT SERVED

Indicate: Basis (PSA):____

Shift:____

Time:_____

(includes only classes which do

Status (ESG):_______

Yes

not constitute a promotion)

Have you ever taken an examination within the past two years for this

class:

( ) Yes

( ) No

Request is based on service in the class of:

Reason for

Request______________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

Employee Please Note: A request for a change in location is valid for the length of time indicated in the respective collective bargaining unit contract. It is the

responsibility of the employee to renew the request at the appropriate time.

Employee’s Signature:_____________________________________________________________________

Date:____________________

____________________________________________________________________________________________________________________________________

ACKNOWLEDGMENT BY (Note: if the employee is not permanent in his/her class, the signature of the College President or Division Head (District Office) indicates an

approval of the requested actions).

Immediate Supervisor:____________________________________________________________________________

Date:______________________

College President or Division Head (District Office): ____________________________________________________

Date:______________________

After acknowledgement, forward to Personnel Commission.

For Office Use Only

Initial Date of Hire: _________________________

Priority Shift Transfer:

Yes:________

No:_________

LACCD Form C1045 rev. 10/15