University Human Resources
Pay Action Request Form
For Classified Employees and University Staff
I. School/Department Information
Organization Name:
Organization Code:
Contact Person:
Email:
Phone:
Fax:
Department/Program Head’s Name
Signature
Date
NOTE: Approval Signatures must be documented in Section V.
II. Employee Data
Employee Name:
__________________________
Role Title:
Position #:
Employee ID#:
_________
Work Title:
Assignment #:
Salaried
Hourly
%FTE
(If different from Employee ID #)
lII. Reason for the Request (See the “Guide to Preparing Pay Action Requests for Classified Employees and
University Staff”: http://www.hrs.virginia.edu/compensation/classification/guidetoparf.html )
NOTE: One request per form. Please select either ONE In-Band Pay Adjustment or ONE Other Pay Action Request .
Type of In-Band Adjustment (IBA): (Select only one) NOTE: IBAs cannot be used to provide internal counteroffers.
Application of New Knowledge, Skills, Abilities, and/or Competencies from Education and/or Training
Change of Duties and Responsibilities
Internal Salary Alignment
Retention
Select Method of Payment:
Base Salary Adjustment
OR
One-time Payment (Non-base adjustment)
Other Pay Action Request:
Temporary Pay (“Acting Pay” in Oracle/HRMS)
Competitive Salary Offer NOTE: Cannot be used to provide internal counteroffers.
Current Salary: $
Requested Salary: $
Amount of Requested Increase: $
Percent of Requested Increase:
Effective Date:
Expiration Date:
(Applies to Temporary Pay Only)
List all previous IBAs received by this employee (if any). Include effective date, IBA type, & percentage increase:
Will this pay action, if approved, create adverse impact to other employees in the School or Dept? No
Yes*
*If “Yes”, provide full explanation. Attach IBA-Internal Salary Alignment Data Template located at
http://www.hrs.virginia.edu/compensation/classification/inbandtemplate.xls identifying impacted employees.
University Human Resources (UHR Use Only)
Effective Date:
Pay Action Expiration Date: _______________ Role Code:
Pay Band: ______
Current USC:
New USC:
If Non-Exempt (√): _________
Salary Info: Current:
New:
Amount of Increase:
% of Increase:
Note to UHR Employee Records:
____________________________________________________________________________________________________________
UHR Reviewed by:
Date:
*Special Authorization (Provide UHR Name/Title):
Keyed by Emp Records:
Date:
rev 08/08/06
Questions regarding the use of pay practices should be directed to your respective School or Department Human Resource
Office or to central University Human Resources Office of Compensation Management at 924-4747/4366 or 243-2204/2206.
IV. Required Pay Factor Documentation
A. Performance-- The requesting manager confirms that the employee’s performance is at least at the
“Contributor” level (meets expectations/satisfactory) in all job elements/core responsibilities.
YES
B. Organizational Business Need (Describe how the primary responsibility of the position contributes to overall success of the organization.)
C. Budget Acknowledgement (The requesting manager confirms funding is available to support this pay action request
for its duration if approved.)
Funding Is Available for this Pay Action Request
YES
D. Justification Detail/Required attachments for all pay action requests:
1. Justification Details – Provide your business justification for this request as a one page or less
attachment. (See the “Guide to Preparing Pay Action Requests for Classified Employees and University Staff”)
2. A current Employee Work Profile/Parts I and II only (Please circle on the EWP any added/changed job
duties, if relevant).
3. A current Organization Chart (Please circle the employee’s name being recommended for a pay increase).


In addition, proposals for IBAs due to “Internal Salary Alignment” should include the IBA-Internal Salary
Alignment Data Template.
In addition, proposals for “Competitive Salary Offers” must include a copy of the external offer letter.
V. Authorizing Signatures
Authorizing Officials: Please indicate your decision regarding
this pay action request by providing your signature below:
Approved Salary
(if modified from
proposed)
Deferred?
Not Approved?
(√ if “Yes”)
(√ if “Yes”)
Compensation Management Advisory Committee
Recommendation (If applicable. Usually refers to IBAs)
________________________________________________
Print or Type Name of Recommending Official
$ ___________
________________________________________________
Signature
Dean/Department Head Reporting to Vice
President**(Required for all pay actions requested)
________________________________________________
Print or Type Name
$ ___________
________________________________________________
Authorizing Signature
**Note: Please forward completed form to UHR Office of Compensation Management. Regarding IBAs only: UHR will
review IBA requests received from Deans/Department Heads prior to review and action by respective Vice Presidents.
UHR will forward IBAs to respective Vice Presidents.
Vice President (Required for IBAs; may include other pay actions.)
________________________________________________
Print or Type Name
$ ___________
________________________________________________
Authorizing Signature
Note: Completed form and required attachments should follow the internal routing procedures established within each School
or Department first. Then forward completed Pay Action Request Form and required attachments to UHR Office of
Compensation Management. Messenger mail address: P.O. Box 400127, Michie South. Physical Location: 914 Emmet St.