Employee Change Form

Please complete the following form to begin the employee change process. Provide as much information as you can, and a member from the HR team will reach out to you to complete the process.

Name of Requestor

Employee Name *

✓

Are there any changes to the Employee's name? If so please provide the changes.

Effective Date of Change * Effective dates can only be on the 1st or the 16th of the month -- exception applies.

Current Role Auto-populated when employee is selected

Proposed Role

Home Department of Proposed Role *

Home Cost Number * Clinic location the employee supports. Select 'Allocated' for multiple locations.

Clinic Assignment

Current Location Auto-populated when employee is selected

Proposed Location

Will this change exemption status?

Yes - From Non-Exempt to Exempt Yes - From Exempt to Non-Exempt No will be staying the same Yes

Is there a current Job Description?

Yes - on file w/HR Yes - will attach No - need HR assistance

Please submit the job description for the new title Upload up to 3 files (PDF, Word, or text). Max 4 MB per file.

Current Supervisor Auto-populated when employee is selected

Proposed Supervisor

✓

If the supervisor is changing, the AI Approver will be updated automatically.

Any other changes in pay to take affect? * Describe any additional pay changes (stipends, bonuses, reimbursements, relocation assistance, allowances, etc.)

Current Pay

Proposed Pay

Compensation data is written to the HR Excel spreadsheet only. It is never included in notification emails, tickets, or logs.

Proposed Employment Status

Full Time Part Time Part Time Temporary Full Time Temporary Per Diem

Proposed Shift Type

5 x 8 4 x 10 N/A

Is the employee already aware of this change?

Yes No

Short description of need *

Eligible for prorated merit increase?

Yes No

Additional Comments

Send me an email receipt of my responses