HomeMy WebLinkAboutPersonnel, Personnel Policy, Unions, Salary Review, Comp Plan - 59 - Grant Mental Healthcare - 32 (068)RECEIVED Grant County
DFC, 2 2 2oo5 Personnel Action Request
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Position Anniversary Date Position Title CLSA
Department Hire Date 2NI�g Department
0 New Employee
Name
Telephone #
Scheduled Days
Emergency #
Hours
Address
XEmployee Information Update
Social Security #
Details/Comments
New Hire Information Only
EEO Function W-4 attached 1:1 Yes E] No Hours per Month
F-1 Fall Time _[T Exempt Regular (Salary) Band _ Step Salary Rate of Pay
n Part Time El Non -Exempt 1:1 Temporar� (Hourly) Hourly Rate of Pay
Type A Actions - to Accounting[Payroll
Check Box that Explains Request
F-1 Address Change Lj Schedule Change 1:1 Insurance Change 0 Retirement System Change Deferred Compensation Change
*The appropriate form must be completed, signed and attached to this form. Obtain the appropriate form from Accounting.
Type B Actions - to Human Resources
Check Box that Best Explains Request and Indicate Requested Change
Routine Step Increase Job Re-evaluation Promotion [_] Status Change E] Other
Type B Action Change From Change To Pay RatelComments
Job Title Change
L1 Step Change Band Step Band
El Other Salary/Wage Change
E] Status Charge
L1Department Transfer
Type C Actions - to Human Resources Comments
FE -1
El SeparationiLayoff Separato,/Rtirement
ESeparation/Resignation 1)� Separation/Other
Separation Specifics E Voluntary Separation 0 Involuntary Separation Notice of COBRA rights Provided on
Separation Date AQ__LL_10 __0S Last Day Worked ia=L_(,0_ Last Day Paid 1j:- �-Q
Extended Leave of Absence
Begin Leave End Leave Personal
F Family/Medical Leave Short-term Disability 0 Long-term Disability El Other/Specify
Manager Signature
Human Resource Signatu
Commissioner Approval
Date
GC 012
Date 1,;�/;ip/o5
Date /0) �)C) os
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