Pitzer College | Office of Human Resources and Payroll Services
Rev 10/2019 BG
Authorization Form to Hire a Pitzer Student Employee (Work Study)
(Work Study Only for 2019-2020 Academic Year)
This form must be completed by the student and the supervisor.
Student Information | To be Completed By Student
Name: ____________________________________________
Preferred Name: ___________________________________
Student ID #: ______________________________________
Mailbox Number: __________________________________
Phone: ____________________________________________
Student Email: _____________________________________
Type of Hire: New Hire (First Pitzer Job) Re-Hire (Additional Pitzer Job)
Work Study: Federal Work Study (FWS) Institutional Work Study (IWS)
FWS/IWS Allotment: $_______________________________
Student can locate allotment amount on the student portal
by clicking on FinAid then selecting the Awards tab.
Position Information | To be Completed By Supervisor
Job Posted on Handshake: Yes No
Date Posted: ______________________________________
Position: ___________________________________________
Department: ______________________________________
Work Location: ____________________________________
Timesheet Approver: _______________________________
Start Date: ________________________________________
End Date: _________________________________________
2019-2020 Academic Year | Fall Semester: September 3, 19 to December 20, 19 | Spring Semester Dates: January 21, 20 May 15, 20
Hourly Rate: $13.00 (as of January 1, 2020)
Hours Per Week*: __________________________________
Department Additional Amount | To be Completed By Supervisor
(For on campus Pitzer departments only. Complete if paying student additional amount from department funds)
Department Additional Amount: $__________________
Total Hourly Rate: $_________________________________
Cost Center: ______________________ Grant: ______________________ Project: ______________________
*Benefits Eligibility: Student Employees become eligible for medical insurance benefits only IF they work at least 30 hours per week in a 12
month Measurement Period as defined by the Affordable Health Care Act. If so, they are then eligible on the first of the month 60 days
after said Measurement Period. The initial Measurement Period starts on the first of the month following the date of hire and runs for a
period of 12 months. Thereafter the ongoing Measurement Period will be from October 4 to October 3.
Supervisor Authorization
Supervisor (Print Name): __________________________________________________________________________________
Supervisor Signature: ____________________________________________
Date: ________________________________
Submit Completed form to Human Resources for Processing
Processed By: _________________________ Initials: ___________ Date: ______________ Checked by Payroll: _______________
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