EMPLOYEE PROFILE MANAGEMENT

Name Prefix: (Dr., Mrs., Mr., Ms.) / Dr.MissMr.Mrs.Ms. / Home Phone:
First Name: / Mobile Phone:
Middle Name: / WVDE Work Phone:
Last Name: / Work Extension:
Name Suffix: (II, Jr., Sr., etc.) / Birth Date:
Social Security #: / Sex:
Race: / American Ind or Alaskan NativeAsian or Pacific IslanderBlackHispanicOtherWhite

Home Address:

Street / City / State / Zip / County

Mail Address:

Street / City / State / Zip / County

EDUCATION LEVEL/YEARS OF EDUCATION EXPERIENCE

Educational Level: / AA - Associate of ArtsAS - Associate of ScienceASO - AssociatesBA - Bachelor of ArtsBA+15 - Bachelor of ArtsBAS - Bachelor of Applied ScienceBAS+15 - Bachelor of Applied ScienceBAT - Bachelor of Applied TechnologyBAT+15 - Bachelor of Applied TechnologyBC - BachelorsBC+15 - BachelorsBS - Bachelors of ScienceBS+15 - Bachelors of ScienceDR - DoctoralJD - Juris DoctorLLB - Bachelor of LawsLLM - Master of LawsLPN - LPNMA - Masters MA+15 - Masters MA+30 - Masters MA+45 - Masters RBA - Bachelor of Arts RegentsRN - RNHS - High School / County Salary Schedule:
Years of Ed. Experience: / Days of Employment: / 200 days220 days240 days241 days261 daysPart time
*National Board Certified: / TeacherCounselorNone / Full-Time Permanent: / Temporary:
National Board Expiration Date: / PT Daily/Hourly Rate:
Name of College Attended: / Retirement (County Only) / TRS Plan 1TDCTRS Plan 3None

TYPE OF ACTION – NOTE: Fill out accounting information below

New Employment
Reclassification
Resignation
Retirement
Transfer / Salary Adjustment
Salary Advancement / Reduction in Force
Return to Duty
Suspension/Dismissal
Termination / Leave of Absence
Medical With Pay
Medical Without Pay
Personal
Parental/Family Leave
Other / Last Day Worked:

NEW ACCOUNT INFORMATION

Position Title: / Position No.:
Effective Date: / Replacing:
Justification:
Division: / Career Technical Ed.Finance and AdministrationSchool EffectivenessSuperintendent's OfficeTechnologyTeaching and LearningWV Board of Education / Home Unit:
Office/OIEP Name: / No. Interviewed:
Work Site (Ex.: Capitol): / Room No.:
Supervisor ID: / Supervisor Name:

NEW ACCOUNT INFORMATION CONTINUED

Fund / Approp. / Unit / Program / FTE / PPC / Base Salary / Annual Increment / Sub Total Salary
NATIONAL BOARD SUPPLEMENT (NBS):
TOTAL SALARY + NBS: / TOTAL INCREMENT: / TOTAL SALARY :
NOTE: National Board Certification Supplement (NBS) applicable to WVDE Coordinator level only.

OLD ACCOUNT INFORMATION (Transfer/Reclassification)

Position Title: / Position No.:
Division: / Superintendent's OfficeFinance & AdministrationTechnologyTeaching & LearningCareer & Technical Ed.Educator EffectivenessWV Board of Education / Office:
Fund / Approp. / Unit / Program / FTE / PPC / Base Salary / Annual Increment / Sub Total Salary
NATIONAL BOARD SUPPLEMENT (NBS):
TOTAL SALARY + NBS: / TOTAL INCREMENT: / TOTAL SALARY :

ATTACHMENTS: (Please check those that apply.)

Employment Application for New Employment
County Salary Schedule Information andComputations/OIEP
Documentation of Salary Supplement
Letter Requesting Leave (Personal, Medical, etc.)
Other / Physician’s Statement for Request for Medical Leave
Copy of Certification License (New Employment/Salary Advancement)
Background Information
Retirement/Resignation Letter
Explain Other:

CHECKLIST FOR OFFICE OF HUMAN RESOURCES

References Checked by Executive Director
Background Check / Offer Letter/Salary/Starting Date Mailed

PROCESS FOR SIGNATURES

  1. Executive Director/Chief Officer/OIEP
  2. Chief Financial Officer/Payroll Supervisor
/
  1. HR Executive Director
  2. Chief of Staff/Deputy Superintendent/State Superintendent

Originator / Date
Chief Officer/OIEP / Date
Chief Financial Officer / Date
Payroll Supervisor / Date
HR Executive Director / Date
Chief of Staff/Deputy Superintendent/State Superintendent / Date

Page 2 of 2