EMPLOYEE STATUS REPORT TO: PERSONNEL DEPARTMENT Date ___________________________ Name _____________________________ Payroll No. _____________________ Job Title ___________________________ Dept. __________________________ Section 1. New Employee Re-hire Regular ________ Temp. ________ Full Time _______ Part-Time _______ Rate of Pay ________________________ Effective Date _________________ Recall Section 2. Change of Job Title Pay Rate Grade Department Section 3. Absence JOB/Grade Change WITH PAY : Sick Leave Other DO NOT USE THIS FORM FOR VACATION REQUESTS Pay Rate Change Dept. Change From: TO: EFF. DATE From_______ Thru ________ Tot. Hrs. Off __________ WITHOUT PAY: _________ Thru _________ Tot. Hrs. Off __________ Kind of Sickness: __________________________________________________ Reason for “Other” Absence: _________________________________________ Section 4. Termination Layoff Temp Layoff: Perm. EFFECTIVE DATE: ________________ LAST DAY WORKED:____________ ELIGIBLE FOR RE-HIRE : YES _________ NO __________ Reason for Separation (And “No Re-hire” Recommendation, If Applicable) _________________________________________________________________ Section 5. Details for Action reported above, as necessary, or other comments as desired ___________________________ (Employee’s Signature) ___________________________ (Dept. Manager’s Signature) General Manager or HR Signature if needed: _______________________________________ This document does not create any contractual rights with Ron*Carter…employment is still on an at-will basis. In addition, Ron*Carter may reduce your compensation due to personal time off. Sick days are not paid absences. Document Location: L:Drive: Human Resources / ESR / ESR Form 2009