PERSONNEL ACTION CHANGE FORM
E
MPLOYEE NAME: EFFECTIVE DATE:
EMPLOYEE ID: POSITION:
DEPARTMENT: GL/BUDGET #:
PERMANENT TEMPORARY IF TEMPORARY, END DATE:
*If the type of change is not listed, the change must be processed in eMAP.
EMPLOYEE PRINTED NAME AND SIGNATURE DATE
DEPARTMENT HEAD/BUDGET MANAGER PRINTED NAME AND SIGNATURE (IF APPLICABLE) DATE
VICE PRESIDENT OR NEXT LEVEL APPROVAL PRINTED NAME AND SIGNATURE (IF APPLICABLE) DATE
RRJ 08/01/18
REASON FOR CHANGE
Extension of Temporary Position Assignment
Department Assignment / Allocation between
Departments
Pay
Supervisor
Work Schedule
Directory Information
Biographic
EXPLANATION FOR CHANGE:
CHANGE FROM TO
PAY $ $
BUDGET/GL
DISTRIBUTION
%
%
%
%
%
%
SUPERVISOR
ALT SUPERVISOR
WORK SCHEDULE
DIRECTORY INFORMATION
EXTENSION MAIL CODE
BUILDING
OFFICE
BIOGRAPHIC
NAME CHANGE (must also provide copy of ssn card)
ADDRESS
CITY
STATE ZIP CODE
HOME PHONE
CELL PHONE
For HR/Budget Office Use:
Colleague eMAP Manage My Benefits HR Processed: / Budget Authorization: PCN:
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signature
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