Personnel Action Form
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1Personnel Action Form
Employee name:_________________________________________
Today's date :________________
Effective date : ____________
Action needed: (Please check all that apply)
Old superseded information
New revised information
Personal
Change of address, phone numbers, etc
Changes in benefits, coverage, or contributions must also be done on the appropriate PEHP, URS, or TIAA
change forms.
Other ____________________________
Employee Signature & Date
Position
Change of work location
Change of compensation coding
Change of title or promotion*
Change in compensation *
Change of supervisor *
Termination of employment *
Other ____________________________
* Items require the signature of the Campus President
Additional details of changes:
(if necessary)
Old superseded information
New revised information
Approvals as required by policy:
Print name
Signature
Date
Supervisor
Director
HR Dept
Campus President
Business Office :
Competed by:
Date:
Employee directory change
Vendor file change
Payroll system change
Shared file/network access change
PEHP notification
PEHP 125 plan change
URS/TIAA notification
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Parent category: Business