* Email to HR before effective date * Employee Status Change Form | 2019

EMPLOYEE STATUS / PAYROLL CHANGE This form is to be used by Department Managers for updating payroll information such as department transfers, pay rate

adjustments, and terminations / resignations (some additional paperwork may be required)

EFFECTIVE DATE: EMPLOYEE INFORMATION Employee Name: Employee #: Last 4 of Social Security #:

XXX – XX - Company (check box): Department / Location: Today’s Date:

SMC ADT Changes made below must be authorized by the supervisor and division manager.

PAYROLL CHANGE – CHECK BOX BELOW CURRENT NEW Department Transfer Hourly Pay Rate (dollar amounts only, specify if “salaried”) Position (Supervisor, Manager, etc.)

Reason for change(s): Check box that applies to payroll change Probationary Period Completed (attach evaluation) Bonus (Merit, Quarterly, etc.)

New Registry / Certification Obtained (attach credential) Department Transfer

Pay Rate (check one): Increase Decrease Resignation (attach resignation letter/email)

Status Change (Full Time, Part Time, PRN) Termination (attach disciplinary form)

Comments / Instructions:

Authorization for employee status change:

Departmental Supervisor Division Manager

** HR – Office Use Only **

HR Administrator

Date Completed