BUFFALO STATE

CURRENT EMPLOYEE CHANGE FORM

Salutation
Select oneDr.Mr.Ms.Mrs.Miss / Last Name, First Name, Middle Initial
Department / Supervisor / Campus Address
CURRENT
(complete all fields for current employee) / NEW
(only complete fields that are changing)
Budget Title
Local Title
Rank or Grade
Line Number
% of Time/FTE
Total Credit Hours or
Credit Hour Equivalent***
Salary
Pay Mode / Select oneAnnualBiweeklyHourlyFee / AnnualBiweeklyHourlyFee
Professional Obligation* / Select oneAcademic YearCalendar YearCollege Year (Specify obligation dates) / Academic YearCalendar YearCollege Year (specify obligation dates)
Number of Courses
Account Title
Account Number
Payroll Expense Type / Personal Service (PS)
Temporary Service (TS) / Personal Service (PS)
Temporary Service (TS)
If TS, expected total compensation =
Source of Funds if Salary Increase Recommended / Specify Account #, PS/TS/OTPS, and/or Line # if applicable:
Effective Date: / Expiration Date:
RECOMMENDATION: Check the appropriate box and select a reason from the drop-down menu.
APPOINTMENT: / Select ReasonRenewal of TermTermTemporaryExtend Existing TemporaryManagement/Confidential PermanentProbationary (Classified Promotion)Probationary (Professional Promotion)Other (specify below)
LEAVE: / Select ReasonCivil Service Sick Leave Half PayFamily/Medical Leave w/PayFamily/Medical Leave w/No PayLeave without PayOther (specify type and percent)Return from LeaveSabbatical (full year @ 1/2 pay)Sabbatical (1 semester @ full pay)Sick leave using accrualsWorkers' Compensation Leave w/o Pay
SEPARATION: / Select ReasonDeceasedExpiration of TermResignation (beginning of business)Retire (beginning of business)Termination (beginning of business)Transfer to another State agency (specify)Other (specify)
EXTRA SERVICE:** / Select Type@ Buffalo State@ another State agency UP-8 (UUP)@ another State agency UP-6 (M/C)Dual Employment (part-time employees)
GRADUATE FACULTY STATUS: / Select Status (if applicable)
REASON / EXPLANATION:
* If College Year obligation is selected, specify obligation dates.
**Ifextra serviceis provided at Buffalo State, list the salary, account title, and number.
***Required field for part-time faculty. This number determines eligibility for health insurance. Your signature certifies the number is accurate.
Resources to complete this form is available at or call HRM at ext. 4822.
1. Supervisor/Department Head/Chair / Date / 4. Budget / Date
2. Dean/Director/AVP / Date / 5. Human Resource Management / Date
3. Provost / Vice President / CIO / Date / 6. President / Date
Distribution: Provost/VP/CIO, Supervisor/Dept Head/Chair, Dean/Director/AVP, Equity & Diversity, Budget, HRM, Benefits, Payroll Rev 10/2018