Status Change Form

STATUS CHANGE FORM

Name*

First Name

Last Name

Reason for Form

Effective Date*

From Status/Department*

Job Title*

To Status/Department*

Pay Rate $

Comments*

Department/Cost Center*

Work Status*

Reports to Email*

Reports To Name

Is this Position Allocated

Yes No

Time Keeper Name/Supervisor

Position Allocation

Indicate the % of split between departments below.

1 - Allocation Department*

1 - Allocation %*

2 - Allocation Department

2 - Allocation %

3 - Allocation Department

3 - Allocation %

Do you need more Allocation Lines?*

Yes No

4 - Allocation Department*

4 - Allocation %*

5 - Allocation Department*

5 - Allocation %*

6 - Allocation Department*

6 - Allocation %*

ALLOCATION MUST EQUAL 100% to Continue

Total Allocation

Separation

Please remember on date of actual separation, the employees badge and keys need to be turned into Security Officer

Type of Separation*

Voluntary Involuntary

Eligible for Rehire*

Yes No

Separation Reason

Date Prox Card Disabled*

Date Computer Access Disabled

Date Phone Disabled

Or Transfer Phone to

SCHEDULE/PAY RULE

Work Schedule*

Please list the hours worked on each day. Both weeks need to be filled out.

Shift

1st (First) 2nd (Second) 3rd (Third) Weekends

Pay Rule*

Meal Deductions*

Yes No