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