
Employee Status Change Form
Employee Name: ___________________________________________________ Social Security #: __________________________________
Address: ______________________________________________________________________________________________________________
DT #: ___________ Location Name: _________________________________ Position: ____________________________________________
Effective Date: ______/______/______ Date of Birth: ______/______/______ E-mail: ________________________________________
Employee Status
Type of Change: New Hire Rehire Employee Status Change
Regular Full Time (30 hours or more) Hours per week: _________
Regular Part Time (29 hours or less) Hours per week: _________
Temporary (Less than 6 months) Hours per week: _________
On Call (As Needed)
Salary Establishment/Change
Type of Change: New Hire Merit Increase Promotion Cost of Living Other _______________________
New Pay Rate: $__________________ per hour Bi-weekly salary amount Annual Salary $______________________
(Non-Exempt) (Exempt) (If Exempt)
IF SCHOOL EMPLOYEE: ( If contracted teacher, please attach a copy of the contract)
# of Pays: _____________ First Check Date: ______/______/______ Final Check Date: ______/______/______
Status Change
Location Change (Transfer) From_______________________________ To ________________________________
Position Change From_______________________________ To ________________________________
Leave of Absence From_______________________________ To ________________________________
Other _______________________________________________________________________
Termination of Employment
Last Working Day: ______/______/______
Eligible for rehire? Yes No (if no, list reason) _______________________________________________________________
Select ONE reason for separation:
Voluntary:
Dissatisfied w/ job or company Retirement School No Call/No Show Better job/pay/benefits/hours
Medical-self or family Relocating Family issues Other________________________________________________
Involuntary:
Poor performance Gross Misconduct Contract Ended Unqualified for job
Violation of company policy/procedure Unprofessional conduct Other________________________________________________
Remarks:______________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Parish/School/Agency Signature:______________________________________________________________ Date:_______________________