Appendix 19
FORM HRM-3
(5/2003)
Change of Status Request
INSTRUCTIONS:
1. This form should be used to report all changes in status including renewals of appointment, changes
in title, changes in salary, changes in obligation, leaves and terminations for all academic, classified
and professional staff including Graduate Assistants and Teaching Assistants.
PAYROLL PER. #
ACTION/ REASON
Department
Line Number


2. See reverse side for detailed directions including definitions, types of changes and required
documentation.
EMPLOYEE DATA
Account No.
Supervisor / Contact Name Phone No. E-Mail
Ad.
Employee's Name (First Name, M.I., Last
Name)
Social Security No.
Appointment Type
[ ] Classified Service
[ ] Professional Service [ ] Assistantship
CHANGE/RENEWAL OF APPOINTMENT TYPE
Permanent Appointment (Requires Chancellor’s approval for Professional Employees)
Renewal of:  Temporary Appointment  Term Appointment
(# of years) from
to


Probationary Appointment (for Professional Employees only)
 Probation completion (Classified Service only)
No changes in terms of appointment
 Change terms of appointment as noted below:
CHANGE(S) IN TERMS OF APPOINTMENT
Present Title
New Title
Effective Date
Ending Date
Present Salary
New Salary
Present Obligation (full-time, part-time %)
New Obligation
Other Status (see reverse for types)
New Status
LEAVES

Sabbatical Leave (see conditions on reverse)

Sick Leave (types of Sick Leave listed on reverse):

Other Leave with full/partial pay (attach justification)

Leave without pay (see types on reverse)

Unauthorized Leave (AWOL)
 FMLA
% of pay
from
to
% of pay
from
to
% of pay
from
to
from
to
from
to
TERMINATION/NON-RENEWAL OF APPOINTMENT

Non-Renewal of Term Appointment

Resigned (attach letter)

Termination of Classified Appointment

Non-Renewal of Temporary Appointment

Retired

Other (types on reverse):
Eff. Date
REMARKS (FOR PART-TIME FACULTY, PLEASE INDICATE COURSE(S) TAUGHT)
POSITION NO.
JOB CODE
PAY BASIS
SALARY RATE
TITLE (MAX.21 POSITIONS)
P.T. %
JR.CL.
INCR CODE
SAL.GRD.
N.U.
APPT.CODE
COURSES TAUGHT LAST SEMESTER / CURRENT SEMESTER
APPROVALS
TRANS. EFF. DATE
TRANS. THRU DT.
ADMINISTRATIVE REVIEW
Signature by applicants for sabbatical leave
agree to conditions
shown on the reverse.
indicates
Employee _______________________________________ Date ________________
(Required for Professional Service leave requests)
Supervisor/
Date ________________
Department Head _______________________________
Financial Mgmt. & Budget _____________________
Dean/Asst/Assoc VP_____________________________
Date ________________
Human
Resources Mgmt.______________________
____________________________
VP/ President___________________________________
Date ________________
Return all 3 Copies to Human Resources
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Types of Changes
Change/Renewal of Appointment Type
Permanent Appointment: See “Reappointment Procedures” for Professional Employees.
Renewal of Temporary Appointment: Indicate beginning and ending dates.
Renewal of Term Appointment: Indicate number of years and beginning and ending dates.
Probationary Appointment: For Professional Employees who have a change in title.
Probation Completion (Classified Service only)
Change Terms of Appointment
Change Title, Salary or Obligation: Complete boxes specified for present and new terms.
Change Scheduled Hours, Shift and/or Pass Days: Complete boxes for other status and new.
Change Line Number: Complete boxes for other status and new or use Remarks if already used.
Change Department, and/or Account/Funding Source: Use Remarks section.
Change Supervisor: Complete boxes for other status and new or use Remarks if already used.
Change Personal Information (Name, SSN, Address, Other): Use Remarks section.
Leaves
Sabbatical Leave at Full Pay (Limited to one semester): See conditions below.
Sabbatical Leave at Half Pay (Up to one year): See conditions below.
Applicants are required to file a statement outlining the program to be followed identifying any
(1) proposed income other than salary from the campus while on leave.
(2) Applicants are required to acknowledge an obligation to return to the University at Albany for
a minimum of one year at the conclusion of their leave. Where justified, the President may
request a waiver of this condition, which must be reviewed and approved by the Chancellor.
(3) If the faculty member fails to return for the minimum period, then he/she is obligated to
reimburse all salary paid during the leave.
(4) All changes to an approved sabbatical plan must be approved, in writing, by the appropriate
campus officer as soon as such need is known. At the University at Albany this will be the
Vice President for Academic Affairs.
(5) The faculty member is required to submit an activity report as soon as possible following the
leave, and no later than the end of the first full semester after return from the leave.
In the event of illness or other unplanned circumstances that interrupt an approved
(6) sabbatical, the faculty member will be placed on another leave as appropriate, when in the
discretion of the President such action is in the best interest of the University and the
Sick employee.
Leave from Sick Leave Accruals: Attach Physician’s statement.
Sick Leave with Full or Partial Pay (After exhaustion of accruals): Indicate percent of pay.
Sick Leave without Pay: Indicate if pursuant to Family and Medical Leave Act.
Other Leave with Full or Partial Pay: Requires Chancellor’s approval for Professional Service.
Leave without Pay: Indicate purpose of leave including probationary leave or child care.
Unauthorized Leave (AWOL): Attach explanation for action.
Termination/Non-Renewal
Non-Renewal of Term Appointment: Indicate effective date.
Non-Renewal of Temporary Appointment: Indicate effective date.
Resigned: Attach resignation letter and indicate if resigning to accept other State employment.
Retired (Must apply to appropriate retirement system to begin collecting retirement benefits).
Termination of Classified Service Appointment: Indicate effective date.
Termination/Leave (Classified Service only): Also complete leave without pay section.
Deceased: Check box for other and indicate date and time (if known) of death.
Approvals
Only Supervisor/Department Head approval required for change in scheduled hours, shift and/or
pass days, sick leave (Classified Service) and AWOL.
Leaves for Classified Service employees are not requested but are reported.
36