Arizona State Personnel System
PERSONNEL ACTION FORM
ALL CAPS INDICATES A REQUIRED FIELD *ATTACH REQUIRED DOCUMENTATION FOR THESE ACTIONS
Agency
Code
Process
Level
Dept.
User
Level
EIN
SSN (New
Employee
Only)
Effective
Date
EMPLOYEE INFORMATION
Preferred Name
(if different)
City
State
County
Zip
Code
Employee's Full Name
(Last, First, MI)
Personal Mailing
Address
Work Telephone/
Extension
Work E-Mail
ACTION TO BE TAKEN (select all that apply)
NEW HIRE/REHIRE*
Covered
Uncovered
Political Appointee (PA)
Regular
Temporary
Return Retiree*
Paid Intern
WITH BENEFITS
Health
Retirement
Leave Accruals
WITHOUT BENEFITS
BOARD MEMBER
Compensated
Non-Compensated
JOB CHANGE
Transfer From
(Agency)
Transfer Within Agency
Demotion
Voluntary
Involuntary
Promotion*
Reversion (Covered Only*)
PA to Non-PA
Non-PA to PA
RIF Job Change*
CHANGES TO POSITION
Funding/Labor Distribution
Supervisor Code/Link
Process Level/Dept./Check Locator
STATUS CHANGE
Covered to Uncovered
FTE Change
PA to Non-PA
Non-PA to PA
FLSA Exempt to FLSA Non-Exempt
FLSA Non-Exempt to FLSA Exempt
SALARY ADJUSTMENT*
Base Pay
Variable Pay
Special Assignment
WORK SCHEDULE CHANGE
PERSONAL INFORMATION CHANGE
OTHER (EXPLAIN IN COMMENTS)
TERMINATION/AGENCY TRANSFER
Resignation
Dismissal
Death
Retirement
Expiration of Appointment
Transfer To
POSITION INFORMATION
Job
Code
Position
Number
Position
Title
FLSA
Exempt Non-Exempt
Grade
Old Base
Rate
New Base
Rate
Variable Pay
WORK SCHEDULE/FTE
Special Assgn.
Pay
HRS.
DAYS
WEEK
Work Sched
ule Work Schedule
Week 1
Week 2
S S M T
W
T F
S
S
M
T
W T F
Employee FTE
Full Time (1.00)
3/4 Time (.75)
1/2 Time (.50)
1/4 Time (.25)
Shift/Differential
SUPERVISOR CODES/LINKS FOR POSITION (Attach organizational chart if new codes are required)
WILL THIS POSITION SUPERVISE
Yes
No
Supervisor link means this position is a supervisor
SUPERVISOR CODE FOR THIS POSITION
POSITION LABOR DISTRIBUTION (Must total 100%; use comment or attach additional sheets if required)
Pct
Acctg. Unit
Acctg. Unit
FY
FY
Acctg. Unit
Acctg. Unit
Pct
COMMENTS
Name
Date
FLEX
ETE Participant
Yes
No
1st / None
2nd / 5%
3rd / 10%
Existing Link
ASPS/HRD-FA1.01 8/18
Signature
Director's
Signature
SPECIAL ASSIGNMENT*
Supervisor Code means this position's supervisor
List EINs of all employees reporting DIRECTLY to this position
FY
FY
Pct
Pct
RIF / Layoff
click to sign
signature
click to edit
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click to sign
signature
click to edit
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