Personnel Action Form
Date: Department:
Last Name: First: Middle:
Address: City: State: Zip:
Phone: Employee #:
SSN: Date of Birth:
Marital Status: Race:
Emergency Contact: Emergency Phone:
Effective Date: Former Employee – Month/Year
Type of Action Requested: New Hire Termination (Resigned, Dismissed, Retired, Death)
Leave with Pay Released from Probation
Leave without Pay Other Explain:
Classification Change
Position Type: Full Time Part Time Other Explain:
Employee Status: Regular Temporary Beginning Date Ending Date
Probationary Intern
Trainee Other Explain:
Present/Last Classification: Position/#: Grade: Salary:
Requested Classification: Position/#: Grade: Salary:
Name of Employee Replaced:
Comments-Additional Information:
HR/Employee Relations Director: Date:
Comments:
Requested By:
Department Head: Date:
APPROVALS
Finance Officer: Date:
Administration: Date:
County Manager: Date:
This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act.
Personnel Action Form (v1.7) 06.14.2022
