Colorado School of Mines
Exemption Request Form
Use this form to make a request to exempt a position from the State Classified Personnel System. Please
provide response to all of the questions that apply and attach any required documents as indicated. The
Exemption Request Packet is then to be submitted in accordance with CSM’s Policy on “Establishing or
Changing Employment Category – Classified and Exempt” which may be obtained in Human Resources.
Date of Exemption Request:
I.
General Information
Position Number:
Department:
Title of Position:
Title of the person to whom this position reports:
Is this supervisor an officer of CSM?
YES
NO
II. Exemption Requested – please check all of the following that apply. Be sure to attach
documents to this request as required by the different types of requests.
Note: If your request requires that a job description is attached, include in the job description the approximate
percent of time spent on each responsibility listed in the job description.
Newly created position – include a current organization chart and a detailed job description.
Existing unoccupied Classified position – include a current organization chart and a detailed job
description.
Re-exemption – job title change only. Include a copy of the letter containing the original
exemption decision.
Re-exemption – change in job duties. Include a copy of both the old and the new job descriptions,
a statement of the changed responsibilities, and a current organization chart.
Re-exemption – reporting relationship change. Include a current organization chart, the previous
organization chart, and a copy of the letter containing the original exemption decision.
Reconsideration – due to a denial of a previous exemption request. Include a detailed statement
of why the original decision was not correct and a statement of why the position should be exempt.
Other – include a statement that clearly explains the circumstances and conditions of the request,
a current organization chart, and a detailed job description.
III. Statutory Exemption Requested: Please check below the Mines procedure paragraph
under which this exemption is being sought.
Procedure 1.2
(a)
(b)
(c)
1. Is the position funded by auxiliary funds?
(d)
YES
NO
Exemption Request Form – Page 2 of 2
2. If the position is involved in the direct delivery of academic curriculum, explain how the position
fulfills this role – be specific in your response.
IV. Position Qualifications – If not provided on the job description, list the educational
qualifications required for the position.
V. Certification: I certify that the information provided on this Exemption Request Form is
true and accurate to the best of my knowledge.
Dated this
day of
, 20
.
By:
_______________________________________________________________________
Signature and Job Title
Date
Department Review & Concur:
_______________________________________________________________________
Signature and Job Title
Date
VP Review & Concur:
_______________________________________________________________________
Signature and Job Title
Date