Georgia Department of Human Resources



Georgia Department of Human Services

Request for Personnel/Payroll Action

|Complete this Section for all Actions – Then use appropriate Blocks |

|Employee ID and/or SS Number:       |Name (Last, First, MI):       |

|Position No.:       |FLSA Status:       |Zip Code:       |MD ID:       |

|Job Title:       |Division/Unit:       |Dept ID:       |

|Effective Date:       |Unit Contact Name:       |Contact Phone:       |

|APPOINTMENT |

|Unclassified Hourly Time Limited Hourly Part-Time Transfer from Other M/S Agency       |

|Job Title:       |Pay Grade:       |Salary:      |

|Job Code:       |Full time Part Time |Hours To Pay:       |

|PROMOTION/DEMOTION *Attach documentation |

|Promotion Voluntary Demotion *Disciplinary Demotion |

|Current Job Title:       |PG:    |Position No:      |Job Code:       | |Salary:            |

|New Job Title:       |PG:    |Position No:      |Job Code:       |% Increase:    |Salary:       |

|LATERAL TRANSFER WITHIN SAME COMPANY |

|Same Class Different Class |

|Current Job Title:       |Job Code:       |Position No:       |

|New Job Title:       |Job Code:       |Position No:       |

|Unit Change To:       |Mail Drop ID:       |

|EMPLOYMENT STATUS CHANGE |

|Percentage of Time |From:       |To:       |

|SALARY CHANGE |

|Disciplinary Salary Reduction Salary Increase Restoration of Salary Reduction Stipend Bonus * |

|Salary Supplement Removal of Salary Supplement Hourly Rate Change Hiring Bonus** |

|Current Salary :      | |% Increase:       |% Decrease      |New Salary:       |

|WORK SCHEDULE: Must be completed for Leave of Absences & Separations that occur in the middle of a pay period. |

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

|      |

| Regular LWOP Short Term LWOP Family Leave W/Pay |

|Military LWOP Contingent LWOP Military Leave W/Pay |

|Suspension W/O Pay Family LWOP Suspension W/Pay |

|Employee worked       out of       scheduled hours. |

|Last Date and Time in Pay Status:       |Last Date and Time Present at Work:       |

|RETURN FROM LEAVE OF ABSENCE |

|Return from Family Leave W/O Pay Return from Family Leave W/ Pay Return from LWOP |

|Return from Suspension W/O Pay Return from Suspension W/Pay |

|Employee worked       out of       scheduled hours. |

|Last Date and Time in Pay Status:       |Return Date and Time:       |

|SEPARATION |

|Release From Employment Resignation Retirement Transfer to Other State Agency |

|No Position Upon Return Reduction in Force (RIF) Dismissal Name of Agency:       |

|Failure to Return from Leave Expiration of Employment Death |

|Employee worked       out of       scheduled hours. |

| Rehire *No Rehire Recommendation * Must attach documentation |

|*Annual Balance:       |*Sick Balance:       |*Total Forfeited Annual & Sick:       | |

|*FLSA Comp:       |*Holiday Hours:       |*Personal Leave:       |Last Date and Time Present at Work:       |

|*Attach a copy of the employee’s leave card | |Last Date and Time in Pay Status:       |

|COMMENTS OR EXPLANATORY REMARKS: |

|      |

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|SIGNATURES: |

|Requesting Official Signature |Date |Phone |

| |      | |

|Approving Official Signature |Date |Phone |

|      |      |      |

Note: For Position Activity, please use the appropriate Position Action Request.

Revised 09/17/04

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