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: |
| |
| |
|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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