CIVIL SERVICE PERSONNEL ACTION FORM

A: Employee
1. Last Name: First Name: Middle Initial: / 2. Employee’s ID #: / 3. Mail Stop: / 4. Position #:

B: Assignment

1. Effective Date: / 2. Job End Date (If Applicable): / 3. Dept. Name: / 4. Dept. #: / 5. Timekeep
6. Action/Reason: (These lists are of the most common actions/reasons. Check all that apply. Use Explanation/Comments section if needed.)
HIRE/REHIRE
(Not Current Employee)
Regular/Permanent
Fills New FTE
Fills Vacant Position
Temporary (not hourly)
PAY RATE CHANGE
Retention Special Pay
Salary Range Other (Explain) / POSITION CHANGE (Current Employee)
Civil Service to Exempt
Demotion
FTE Change
Promotion
Reallocation
NDR (New Duties—No Search)
JRC (Job Audit Requested)
Temp Assignment Change
Transfer Lateral / DATA CHANGE
Budget
Department
Pay Group
Supervisor
Time Keep
Other (explain) / SEPARATION
Death
Disability
Resignation
Retirement (Full)
Termination (Discharge)
Other (explain)
Explanation/Comments:

C: Job Information

1.  Job Code #: / 2.  Job Title: / 3.  Department Head: / 4. Standard Hours: / 5. FTE:
Yes No
6. Supervisor’s Name: / 7. Supervisor’s Position #: / 8. Supervisor ID#: / 9. Earn Code:
10. Pay Group: / 11. Cyclic Calendar (Holiday Schedule):
Works 12 mo./yr. (CLA)
Cyclic, Academic Year (CCY) mo. **
Cyclic, Non-academic Year (CYW) mo. **
** Enter initial year cyclic leave without pay schedule in comments section. / C085 (8.5 Mo Cyclic Year) C105 (10.5 Mo Cyclic Year)
C090 (9 Mo Cyclic Year) C110 (11 Mo Cyclic Year)
C095 (9.5 Mo Cyclic Year) C115 (11.5 Mo Cyclic Year)
C100 (10 Mo Cyclic Year) C120 (Works 12 mo./yr)
D: Department Budget Table
1. Dept #: / 2. Project ID#: / 3. Operating Unit / 4. Percent / 5. FRS Budget: / 6. Funding Start Date / 7. Funding End Date (If Applicable)
HR USE ONLY
E: Compensation: /

On Salary Plan: BUA CLA

Range: Step:
Salary: PID: / Eligible for Shift Differential or Shift Premium pay?
Yes No
Shift Differential/Premium semi-monthly rate $:______
Bargaining Unit:
None BU (specify #)

Supervisory Code: Civil Service Hourly Title Only

F: Leave Plans:
/ SK LV (50) CLA VAC LV (51) HOLIDAY EQUIV TIME (5H) COMP TIME (5Z)
PH (52) UPL (5B) CYCLIC (5C): HOURS
G: Signatures
Signatures must be in BLUE INK to signify original. (Make copies as needed)
1.  PAF Originator/Contact Person / Date: / Mail Stop / Phone # / 5. Accountant (Grants Only) / Date: / Mail Stop
7469
2. Department Head / Date: / Mail Stop / 6. Human Resources / Date: / Mail Stop
7425
3. Appointing Authority / Date: / Mail Stop / 7. Budget / Date: / Mail Stop
7494
4. Secondary Appointing Authority / Date: / Mail Stop / Position Funding Change / Appointment Funding Change

FOR HR USE ONLY: Empl Rcd # _____ Add Pay # _____ q C: Benefits (Hires/Separations) q Dept Change Form: Completed by______

Data Entry by: / Date: / Verification by: / Date: / Copy Sent to PAF Originator by: / Date:

REV 3.20.12 HR