Personnel Action Form First and Last Name (required) Effective Date: (required) Position: (required) If New Employee, complete the following: Address: City: State: Zip: Phone Number: Date of Birth: Scocial Security No. Person to Notify in Case of an Emergency: Relationship: Telephone: Reason for Change: New Employee Introductory Market Adjustment ELH/PTO Adjustment Annual Review Leave of Absence Demotion Responder Promotion Separation Reclassification Non-Responder Other: If extended leave, indicate reason: Other: Wage Adjustment: Current - To (Changed Status) Position: Current - To (Changed Status) Supervisor: Current - To (Changed Status) FLSA Classification (Exempt vs non-exempt) Human Resources Signature Date Supervisor Signature Date Deputy Chief Signature Date Finance Signature There was a problem saving your submission. Please try again later. Please wait while your submission is being saved... Submitting...Submit Thank you, your submission has been received.
