Employee Information Form

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Fill in as appropriate
CDS in Texas
EFFECTIVE DATE (req'd)
PAYROLL CHANGE / WAGES & BENEFITS / OTHER
CHANGES
Employee name:
Hire Date:
Last 4 digits of Social Security #
REASON FOR CHANGE (Please check one or more pertinent boxes)
ADDRESS CHANGE
RESIGNATION
NAME CHANGE
RETIREMENT
NEW HIRE
DISCHARGE
INCREASE - ATTENDANT
LAYOFF
INCREASE - RESPITE
OTHER
PAY DECREASE
REQUIRED ON ALL DISCHARGES:
LAST DAY WORKED:
REASON FOR DISCHARGE:
ELIGIBLE FOR REHIRE?
YES
NO
ADDITIONAL COMMENTS:
NEW ADDRESS & PHONE NUMBER CHANGE
Street:
City, State Zip:
Primary Telephone
Secondary Telephone:
EMPLOYEE NAME/ POSITION OR PAY CHANGE
CHANGE
From
To
NAME CHANGE:
PAY - PAS
PAY - RESPITE
PAY - Other:
Client Name:
Employer Signature:
DATE
(OR DESIGNATED REPRESENTATIVE)
pg 1 of 1
HR_STATUS_CHG.xls 03/01/02

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