Prepared by:
Ext:
Section 1 Employee Information
Affiliation:
OPSEU MAC Senior Admin. RFA RFA Associate (Admin Appointment) CUPE 233 CUPE PT&S
Last Name:
First Name:
Employee Number:
Title:
Department/School:
Position Number (if known):
Section 2 Salary Change, Bonus, Gift or Award (to be completed for changes to existing salary)
Effective Date (mm/dd/yyyy):
End Date (mm/dd/yyyy) if applicable:
Acting/Temp Allowance (%
increase to salary):
Acting/Temp Assignment (Salary/Wage
Rate):
Other - New Salary and Rationale:
RFA Overload:
Overload Hours:
Overload EI Hours:
Overload Total:
CUPE PT&S (Unit 1):
Extra Student Payment:
Pay in Lieu of Notice:
Service Adjustment:
Section 3 Work Schedule Changes
Start Date (mm/dd/yyyy):
End Date (mm/dd/yyyy): if applicable
New Weekly Hours:
Section 4 Leaves of Absence (please attach original employee request for leave/leave extension)
New Extension Revision
Note: If an employee will take vacation at the end of an approved leave,
please indicate vacation dates under “Other”
TYPE OF LEAVE:
START DATE (first day of leave) mm/dd/yyyy:
END DATE (last day o f leave) mm/dd/yyyy:
Pregnancy
Parental
LTD
WSIB
Other (specify):
Section 5 Non-Work Period (Partial-year employees only)
Note: All CTO credits and vacation credits may be applied to the end of
the scheduled work period, or paid out. Maximum of 10 days vacation
can be carried over.
Start of Non-Work Period (mm/dd/yyyy):
(Last paid day- including any
vacation/CTO paid days)
End of Non-Work Period
(mm/dd/yyyy):
(First day Back at Work)
Pay out ___________ Vacation days and
remaining CTO Credits
Pay out Remaining
Vacation/CTO Credits
Section 6 Termination (Please attach original termination document (ie: letter of resignation, retirement letter etc…)
Resignation Retirement Early Retirement Termination Other(please specify):
Date Last Worked (mm/dd/yyyy):
Termination Date (mm/dd/yyyy) :
Vacation Days to be Paid:
CTO Hours to be paid:
Section 7 Departmental/Faculty Authorization
Distribution Code: Split: Effective Date:
[__ ][__ __ ][__ __ __ __ __ ][__ __ __ __ ][__ __ __ __ ][__ __ __ __ __ __ __ __ __ ][__ __ __ ] $____________ %___________ ___________________
[__ ][__ __ ][__ __ __ __ __ ][__ __ __ __ ][__ __ __ __ ][__ __ __ __ __ __ __ __ __ ][__ __ __ ] $____________ %___________ ___________________
[__ ][__ __ ][__ __ __ __ __ ][__ __ __ __ ][__ __ __ __ ][__ __ __ __ __ __ __ __ __ ][__ __ __ ] $____________ %___________ ___________________
I confirm that the above changes are consistent with Ryerson policies, Collective Agreements, and applicable legislative requirements.
Department Authorized Signature:_______________________________Name:_________________________________ Date:_____________________
Dean/Sr. Director (if required): Name: Date:
Distribution: (1) VP Faculty Affairs (all RFA)__________ (2) Copy to Employee (3) Original to Human Resources Sept 2010
Personnel Action Form (PAF)
For use to initiate changes to existing information for current employees
!!PLEASE PRINT CLEARLY
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