Fillable CHANGE OF STATUS FORM (Servant HR)

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CHANGE OF STATUS FORM (Servant HR)

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The CHANGE OF STATUS FORM (Servant HR) form is 1 page long and contains:

  • 0 signatures
  • 42 check-boxes
  • 23 other fields

Country of origin: US
File type: PDF

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Change of Status Form - SHR 0916
CHANGE OF STATUS FORM
Employee Name Worksite/Client Location Date
Social Security Number Effective Date of Change Department
ACTION ITEM(S):
New Hire Rate of Pay - $
Check One
: □ FT □ PT □ TEMP
Check One
: □ HOURLY □ SALARY
Rehire Rate of Pay - $
Check One
: □ FT □ PT □ TEMP
Check One
: □ HOURLY □ SALARY
Pay Rate Change
New Rate of Pay - $
Position Change
New Job Title Department
Termination*
Last Day Worked Eligible for Rehire
Check One
: □ Yes □ No
Reason
Check One
: □ Job Performance □ Quality of Work □ Attendance
□ Conduct Issues □ Drug Test Results
□ Gross Misconduct □ Other
*
Attach completed
Employee Notice of Termination
Resignation*
Eligible for Rehire
Check One
: □ Yes □ No
*
Attach completed
Employee Voluntary Resignation
Lay-Off
Anticipated Reinstatement Date:
Status Change
Check One:
□ Full-time to Part-time □ Part-time to Full-time
□ Temporary to Full-time □ Full-time to Temporary
□ Temporary to Part-time □ Part-time to Temporary
Leave of Absence
Check One:
□ Personal □ Medical □ Family
□ Other:
Name Change
New / Corrected Name
Address Change
New Address
New Phone # and/or Email
Notes
:
Authorized Signature Date
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CHANGE OF STATUS FORM (Servant HR)

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Completed 16 December 2020

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