Louisiana Department Of State Civil Service

LOUISIANA DEPARTMENT OF STATE CIVIL SERVICE

EMPLOYEE CHANGE FORM

FOR PROGRAM SUPPORT AGENCIES

Effective Date: / LaGov HCM (ISIS) Personnel Number:
Nature of Action: / C.S. Rule Number for Action:
Agency Name: / Agency Personnel Number:
Employee’s Name:
(Last name, First name, MI) / Permanent Status: ☐ Yes ☐ No ☐ N/A
Effective Date:
FLSA Status: ☐ Exempt ☐ Non-Exempt / C.S. Rule Number for Pay:

CURRENT PROPOSED

JOB TITLE
JOB CODE
POSITION NUMBER
PAY SCHEDULE/GRADE
PAY RATE
(OTHER PAY)
WORK HOURS
Assignment End Date / Adjusted Service Date:

The next line is to be completed if employee is going from an unclassified position to a classified position.

Contract Type: / Job posted by Civil Service:
Yes No

Check here if this a new address

Check here if you are reporting a change of address only on this form

Check here if you are reporting a name change only on this form

Employee’s Address: / City / State / Zip
Contact Name: / E-mail Address: / Phone:
I hereby certify that all information on this document is true and correct to the best of my knowledge.
Appointing Authority Signature: / Title: / Date:
Comments/Justification for Temporary Appointments:

Forms may be mailed, faxed or scanned and e-mailed to your Analyst: Department of State Civil Service Phone: (225) 342-8274

Program Support Unit Fax: (225) 342-0966

P O Box 94111

Baton Rouge, LA 70804-9111