Employee Request Form - VA Research



EMPLOYEE REQUESTName of Employee: "Text6"?????"Text7"?????"Text8"?????"Text9"?????"Text10"????? Date of Hire: "Text12"?????Position is Expected to Continue for: FORMCHECKBOX More than 1 Yr or FORMCHECKBOX Expected End Date: "Text4"?????"Text13"?????POSITION INFORMATION Title: "Text14"?????"Text15"?????"Text16"?????"Text17"?????"Text18"?????"Text19"?????"Text20"?????"Text21"?????"Text22"?????"Text23"?????"Text24"?????"Text25"?????"Text26"?????"Text27"?????"Text28"?????"Text29"?????**ATTACH A JOB DESCRIPTION OUTLINING AT LEAST 3 CRITICAL ELEMENTS OF THE POSITIONSee TVAREF if you need an example.Work Place:Bldg/Rm: "Text30"????? FORMCHECKBOX VA Tampa FORMCHECKBOX FORMCHECKBOX Other: "Text31"?????"Text32"?????Mail Stop: "Text30"?????Extension:"Text30"?????Licenses and Privileging Approval: FORMCHECKBOX Is Required FORMCHECKBOX Is Not Required(Required when employee is engaged in patient care)PAY INFORMATIONProject Title/PI:Pay Rate:$"Text30"????? Per FORMCHECKBOX Hour FORMCHECKBOX Month Approximate Hours per Week: "Text30"?????ORPercent Effort: "Text30"????? FORMCHECKBOX Fixed Schedule FORMCHECKBOX Flexible Schedule (Approx. the same schedule each week) (Approx. the same number of hrs each wk) FORMCHECKBOX Intermittent Schedule (Variable Schedule and Hours)OTHER EMPLOYMENT FORMCHECKBOX VA/COIN FORMCHECKBOX UW Current Wage Grade/Step________________Employee certifies by signature at the bottom of this form, all hours charged to TVAREF do not conflict with other work hours.BENEFITSCheck benefits for which employee is eligible: FORMCHECKBOX Annual and Sick Leave (Consistent hours of >20hrs/week or more with an expected appointment of > 3 months) FORMCHECKBOX NONEEmployeeDateSupervisorDateExecutive DirectorDatePersonnelDateOffice Use OnlyDistribution code: ________/_________/________/________/_______/_________ ................
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