Revised 09/2017
Person
nel Status Change Form
Human Resources Department
10 East South Street
Wilkes-Barre, PA 18766
570-408-4630 | fax x7879
Supervisor: Complete all that applies for any personnel change (i.e., new hire, transfer, promotion, stipend, and termination)
First Name MI Last Name Employee WIN
Status Ch
ange(s)
To be completed by Supervisor. (Check all that apply to status change)
( ) New Hire ( ) Transfer
( ) Salary ( ) Promotion
( ) Retire
( ) 9 Month
( ) 10
Month
( ) 12 Month
Faculty
Only
( ) Tenure Track ( ) Non-tenure track
( ) Semi-Monthly ( ) Adjunct
Staff
Only
( ) Full time ( ) Bi-Weekly ( ) Temporary
( ) Part Time-Hrs/Wk:____ ( ) Other
Effective Date: End Date (If applicable)
Previous New (if no change, write same)
Position Title
Department Name
Annual Salary or Hourly Rate
Supervisor
To be completed by Human Resources
Position Number Employee Class Salary Grade
Stipend or
Grant Request (circle the one that applies)
To be completed by Supervisor.
Total $____________ Effective Date______________ Position #____ ______________
Justification:
Budget
To be completed by Supervisor/Budget Manager. (Complete only if different than current position established)
Termination
To be completed by Supervisor. (Attach letter of resignation and forward to HR)
Resignation Effective Date Last Day Worked
Indicate Reason for Separation
( ) End of Contract ( ) Position Abolished ( ) Terminated – Eligible for Rehire ( ) Terminated – Ineligible for Rehire
( ) Retirement ( ) Deceased ( ) Voluntary Resignation ( ) Other ___________________
Signature of Grant Officer
(Signature of Grant Officer required if position is Grant Supported)
Date:
Signature of Department Supervisor Date:
Signature of Next Level Supervisor Date:
Signature of President/Vice President/Provost Date:
Signature of Human Resources Date:
Other_____________
Comments:
