Name



|Name:       |Employee ID (six digits):       |Dept./School:       |

| | | |

| | |RC Number:       |

|ACTION |REASON |REQUIRED INFORMATION |

|POSITION CHANGE |Position Change within | |Designation/Teacher in | |Proposed | |

|(rc mgr |Department/School | |Charge | |Effective Date:      | |

|headmaster | | | | | |Title:      |

|principal | | |Job Reclassification | |To Position | |

|signature) | | | | |Number:      | |

|required) | | | | | | |

|LEAVE OF ABSENCE/|Following Adoption | |Education/Study | |Effective Date:      |Return Date:      |

|RETURN FROM LEAVE| | | | | | |

|(rc |Family & Medical | |Military Service | | | |

|mgr/headmaster/pr|Leave Act | | | |Position |Title:      |

|incipal signature| | |Personal Reasons | |Number:      | |

|required) |Maternity/Paternity | | | | | |

| | | |Personal Illness | | | |

| | | | | | | |

| | | |Return from Leave | | | |

|TERMINATION/ |AWOL | |Retirement | | | |

|RETIREMENT | | | | |Effective Date:       | |

| |Discharge for Cause | |Death | | | |

| | | | | | | |

| |Dismissal | |Failed Probationary | | | |

| | | |Period | | | |

| |Non-R/A | | | | | |

| | | |Resignation | | | |

| |Layoff | |(letter from employee required) | | | |

|PAY |Adjusted Payroll Date | |Career Award (Specify) | |For HR Use Only |

|ADJUSTMENT |(Civil Service – original | |      | | |

| |documentation required) | | | |Effective Date:      |

|(employee | | |Salary Lane (Specify) | | |

|signature |Salary Step (Specify) | |(original transcripts required) | | |

|required) |      | | | |Old Salary:      |

| | | |Tuition Reimbursement | | |

| |Outside Service (original | |(original transcripts, | | |

| |documentation required) | |documentation of payment and | | |

| | | |signed affidavit required) | | |

|Originator’s Signature:       | | |

| | |Date:      |

| |Approved | | |

|For HR Use Only: | | | |

| |Not Approved |HR Signature:      |Date:      |

PLEASE NOTE: All hiring of staff new to the department/school should be completed through the BPS Recruiting Center in Kenexa. The PS03 form will no longer be used for hiring. Please contact the Office of Human Resources with any questions.

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Additional Explanation (if necessary):

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