Employee Status Change Form
Employee Name: ___________________________________________________ Social Security #: __________________________________
Address: ______________________________________________________________________________________________________________
DT #: ___________ Location Name: _________________________________ Position: ____________________________________________
| Effective Date: ______/______/______ | Date of Birth: ______/______/______ E-mail: ________________________________________ | 
|   |   |   |   |   | 
| Employee Status |   |   |   |   | 
| Type of Change: | New Hire |   | Rehire | Employee Status Change | 
| Regular Full Time | (30 hours or more) |   | Hours per week: _________ | 
| Regular Part Time | (29 hours or less) |   | Hours per week: _________ | 
| Temporary | (Less than 6 months) | Hours per week: _________ | 
| On Call | (As Needed) |   |   |   | 
|   |   |   |   |   | 
| Salary Establishment/Change |   |   |   |   |   |   |   |   |   | 
| Type of Change: |   | New Hire |   | Merit Increase | Promotion | Cost of Living | Other _______________________ | 
| New Pay Rate: | $__________________ | per hour |   | Bi-weekly salary amount | Annual Salary $______________________ | 
|   |   |   |   | (Non-Exempt) | (Exempt) |   |   | (If Exempt) | 
| IF SCHOOL EMPLOYEE: ( If contracted teacher, please attach a copy of the contract) |   |   |   | 
| # of Pays: _____________ | First Check Date: ______/______/______ | Final Check Date: ______/______/______ | 
|   |   |   |   |   |   |   |   |   |   |   | 
|   |   |   |   |   |   |   |   |   |   |   | 
| Status Change |   |   |   |   |   |   |   |   |   |   | 
| Location Change (Transfer) |   |   | From_______________________________ To ________________________________ | 
| Position Change |   |   | From_______________________________ To ________________________________ | 
| Leave of Absence |   |   | From_______________________________ To ________________________________ | 
| Other |   |   |   | _______________________________________________________________________ | 
|   |   |   |   |   |   |   |   |   |   | 
| Termination of Employment |   |   |   |   |   |   |   |   |   | 
| Last Working Day: ______/______/______ |   |   |   |   |   |   |   | 
| Eligible for rehire? | Yes | No (if no, list reason) _______________________________________________________________ | 
| Select ONE reason for separation: |   |   |   |   |   |   |   |   | 
| Voluntary: |   |   |   |   |   |   |   |   |   |   | 
| Dissatisfied w/ job or company | Retirement | School | No Call/No Show |   | Better job/pay/benefits/hours | 
| Medical-self or family |   | Relocating | Family issues | Other________________________________________________ | 
| Involuntary: |   |   |   |   |   |   |   |   |   |   | 
| Poor performance |   |   | Gross Misconduct | Contract Ended |   | Unqualified for job | 
| Violation of company policy/procedure |   | Unprofessional conduct | Other________________________________________________ | 
|   |   |   |   |   |   |   |   |   |   |   | 
Remarks:______________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Parish/School/Agency Signature:______________________________________________________________ Date:_______________________