Transfer Request Template - Kaiser Forms
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1
2TRANSFER REQUEST
RECRUITMENT SERVICES DATE STAMP
PLEASE PRINT OR TYPE (NOTE: FORM MUST BE COMPLETED IN ITS ENTIRETY.)
CHECK ONE:
REQUEST FOR OPEN POSITION. POSTING NO. __________________ THIS REQUEST IS VALID FOR THIS POSITION ONLY.
REQUEST FOR FUTURE REPRESENTED OPENING PER BARGAINING UNIT LANGUAGE.
NAME
EMPLOYEE NO.
SOCIAL SECURITY NO.
HOME ADDRESS
WORK PHONE (TIE LINE/EXT.)
DAY TIME PHONE
HIRE DATE
START DATE IN PRESENT POSITION
CURRENT POSITION
REQUESTED POSITION
LOCATION
DEPARTMENT / UNIT
POSITION TITLE
STATUS (Specify)
FT
PT
SH
ON-CALL
PER DIEM
FT
PT
SH
ON-CALL
PER DIEM
SHIFT (Specify)
DAY
EVENING
NIGHT
VARIABLE
DAY
EVENING
NIGHT
VARIABLE
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2
SUPERVISOR / TIE LINE & EXT.
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2
TYPING SPEED
10 KEY/CALCULATOR
MEDICAL TERMINOLOGY
BI-LINGUAL
W.P .M.
SIGHT
TOUCH
YES
NO
YES
NO
IF YES, INDICATE LANGUAGE:
COMPUTER SKILLS
YES
NO
IF YES, INDICATE WHAT SOFTWARE:
PROFESSIONAL LICENSE/CERTIFICATION
DATE OF EXPIRATION
DO YOU HAVE A RELATIVE WORKING FOR THE KAISER PERMANENTE MEDICAL CARE PROGRAM?
YES
NO
IF YES, PLEASE LIST WHO AND WHERE
LIST EDUCATIONAL DEGREES, COURSES COMPLETED OR SPECIAL SKILLS THAT WOULD BE APPLICABLE TO THE POSITION YOU ARE REQUESTING:
OTHER INFORMATION/EXPERIENCE CONCERNING YOUR QUALIFICATIONS FOR THIS POSITION:
IF YOU WOULD LIKE TO SUBMIT ADDITIONAL INFORMATION, PLEASE ATTACH A RESUME.
EMPLOYEE SIGNATURE
DATE
FOR RECRUITMENT SERVICES USE ONLY
Employee’s Seniority Date/Hours __________________
Position open.
Request received within posting period.
Position closed.
Request not received within posting period.
Request will be maintained per bargaining unit language.
DISPOSITION (TO BE COMPLETED BY RECRUITMENT SERVICES/HIRING MANAGER)
Hired.
Interviewed. Not Hired.
Not Interviewed. Not Hired.
REASON NOT HIRED (Check one)
Candidate Refused Offer
No Call/No Show for Interview
Candidate Withdrew
Position Cancelled
Did Not Meet Minimum Requirements ________________________
Unable to Contact
More Senior Candidate Selected
Unable to Work Required Days/Shift
More Suitable Candidate Selected
Other: __________________________________
RECRUITMENT SERVICES/HIRING MANAGER SIGNATURE
DATE
NS-8515 (8-99)
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