**COMPLETE THIS FORM IN CONSULTATION WITH YOUR ASSIGNED HUMAN RESOURCE CONSULTANT.**
- ACTION
Agency Name:
-----Accountancy, State Board ofAfrican-American Affairs, WA State Commission onArchaeology and Historic Preservation, Dept ofArts Commission, WA StateAsian Pacific American Affairs, Commission onBlind, Dept of Services for theBlind, WA School for theCaseload Forecast CouncilCharter Schools CommissionCitizens Comm on Salaries for Elected Officials,WAColumbia River Gorge CommissionConservation Commission, StateCounty Road Admin BoardCriminal Justice Training CommissionEconomic and Revenue Forecast CouncilEconomic Development Finance AuthorityEnvironmental and Land Use Hearings OfficeHealth Care Facilities AuthorityHispanic Affairs, Commission onHistorical Society, Eastern WA StateHorse Racing Commission, WA StateHuman Rights CommissionIndian Affairs, Governor's Office ofIndustrial Insurance Appeals, Board of or -----Joint Transportation CommitteeJudicial Conduct, Commission onLaw Enforcement Officers and FF Plan 2 Rtrmnt BrdLieutenant Governor, Office of theMinority and Womens Business Enterprises,Office ofPilotage Commissioners, Board ofPollution Liability Insurance AgencyPuget Sound PartnershipPublic Disclosure CommissionRecreation and Conservation CommissionState Actuary, Office ofTax Appeals, Board ofTraffic Safety CommissionTransportation Improvement BoardVolunteer FF and Reserve Officers, Board forWorkforce Trng and Education Coordinating Board / Effective Date:
(If: LOA use 1st day on leave; separation use last day in pay status) / Recruitment #:
Offer Accepted Date:
Action Type: SelectAppointment ChangeBasic Pay Update OnlyChange of StatusConcurrent EmploymentLOA-ActiveLOA-InactiveLOA-Return FromNew HirePosition ChangeRehireSeparation / Action Reason:
-or-
Separation Reason: / -----Adjust Hours WorkedDemotion (Specify:Dscplnry;ILO Layoff;Voluntary)ElevationExemptInternshipInTraining(Specify:Begin;Lvl/SeriesComplte;Extend)Layoff (Specify:LO List;LO Optn Accptd,TempRedHrs)LOA Reason (Specify:FML;LWOP;Med;Other*DESCRIBE*)Non-EmployeeNon-Perm (Specify: NP Limited; NP On-Call; Extend)Non-Perm to PermanentOther (Specify)PermanentProbationaryProjectPromotionReallocation (Specify:Up;Down;No Sal Change)ReassignmentReduction in Pay - DisciplinaryRetireeReview Period-Extend (Specify:Prob;Trans;TS;WMS)Season-CareerTransferWMS
-----Abandonment of PositionConditions Not MetDeathDisability - InvoluntaryDisability - VoluntaryDismissalEnd of AppointmentGeneral Govt to Higher EdLayoffLayoff - VoluntaryNon-EmployeeResignRetirementRetirement - Incentive PayReversionSeasonal - Career Layoff 3-8 monthsSeasonal - Career Layoff 9+ monthsSettlement PayTransfer to another state agencyVoluntary - Incentive Pay
TASK MONITORING: / Task: Select Task:Not ApplicableIn-Training StepIn-Training PlanLeaveNon-Perm AppointmentProjectWMS Acting / Expected end date: / Review Period: YES NO If yes, length:months
- EMPLOYEE
*****If this action is due to a new hire, rehire, or new appointment to your agency, submit a completedEmployee Questionnairewith the PPDS*****
Last Name: / First Name: / M/I: / Employee ID #:
(if new to state use SS#) / Prior State Service
YES NO
ADDRESS & PHONE: / Permanent Address: / City: / State: / Zip:
Mailing Address (if different): / City: / State: / Zip:
Primary Phone: / Alternate Phone: / Type: SelectWorkCellOther / Work Email:
PERSONAL DATA: / Gender:Male Female / Date of Birth: / Marital Status: SelectSingleMarriedDivorcedWidowedUnknown / since:
- POSITION & ORGANIZATIONAL ASSIGNMENT
Job Class Title: / Job Class Code: / Working Title (if different than Job Class Title):
8-Digit Position #: / 4-Digit Position #: / Status in Position:SelectActingBoard/CommissionExemptIn TrainingIn Trng/ProbIn Trng/Trl SrvNon-EmployeeNonPerm LimitedNonPerm On CallPermanentProbationaryProjectProject/ProbProject/Trl SrvSeasonalSeasonal/ProbSeasonal/Trl SrvTemporaryTransitionalTrial ServiceWMS Review / Overtime Eligible YES NO
L&I Code: Select4902 - Admin Clerical5300 - Admin Clerical w/ travel5307 - NOC (not otherwise classified)6901 - Volunteers / Duty Station: SelectClark CountyKing CountyKitsap CountyMason CountyPacific CountyPierce CountyThurston CountyOut of StateOther / Org Key (optional):
Employee Self Service (ESS):
required for ESS users / Does Agency Use ESS:
YES NO / Is this employee an ESS Leave Approver:
YES NO / Supervisor Name: / Supervisor Position #:
- BASIC PAY No Change
Reason:Select01: Periodic Increment02: Rng Inc OFM Director Action03: Rdctn in slry Discipline04: Return from Rdctn in slry05: Salary Adjust - Leg Action06: W Rate (WMS Only)07: Y Rate (Non WMS Only)08: WMS Raise - Int Slary Rel Prob09: WMS Raise - Growth/Development10: WMS Raise - Recruit/Retention11: Employee on Disability Pay12: Employee off Disability Pay13: Add Additional Pay14: Remove Additional Pay17: Salary Adjust-Equity/Alignment18: Salary Adjust-Recruit/Retent19: Initial/Rehire Appointment20: Appointment Change21: Salary Adjust-Statutory Auth23: Add WMS Extraordinary Resp24: Remove WMS Extraordinary Resp25: Non-Employee26: Longevity / Salary: $ Per: Year MonthDayHour / Band/Range: / Step:
Eligible for Assignment Pay
Is a premium added to base salary to recognize specialized skills and assigned duties? / YES NO
Type:SelectAP REF 9 Floor Care CrewAP REF18 Dual LanguageAP REF51 High Voltage / Eligible for Shift Differential
Does employee’s regular or temporary scheduled work shift include hours after 6:00pm and before 6:00am? / YES NO
- WORK SCHEDULE No Change
Work Schedule:SelectFULL: 5-8s M-FR015: 4-10s M-THR017: 4-10s T-FR228: 4-10s M-T, TH-FR031: 4-9s/4 M-TH 9, F 4R044: 2wk:M&W-F9, T0, 2nd T 8R045: 2wk: M-TH 9, F 8, 2nd F 0R048: 2wk: M-T&TH-F -9, W8, 2nd W0R051: 2wk: M 8, T-F 9, 2nd M 0R049: 2Wk: M-F 9, 2nd T 8, F 0R271: 8.5s/6: M-TH 8.5, F 6R281: M,W,F 10, T, TH 5R283: M,W: 8, T,TH:10, F:4R353: M:0/2nd M:8, T-TH: 12R030: 24/7 (hourly)Other (Specify)
Other: / Shift Hours: Start Time: ampm
End Time: ampm / Full Time (100%) Part Time %
Teleworking:Is/will employee be working from home or another alternative location closer to home? SelectNot ParticipatingParticipating: Less than 1 day every two weeksParticipating: 1-2 days every two weeksParticipating: 3-4 days every two weeksParticipating: 5 or more days every two weeksOther (Specify)
- BENEFITS No Change
Insurance Eligible
Is the employee expected to work an average of 80 hrs/month (at least 8 hrs/month) for more than 6 months? / YES NO / Eligible for Personal Holiday
Is the employee scheduled to be, or has been, continuously employed 4 months? / YES NO
Retirement Eligible
Note: Eligibility is based on the position. / YES NO / Eligible for Personal Leave Day (Represented Only)
Is the employeescheduled to be, or has been, continuously employed 4 months. (6 months if Coalition or Teamsters) / YES NO
- BUDGET No Change
Percentage: / Fund: / Appropriation Index: / Program Index: / Project:
Percentage: / Fund: / Appropriation Index: / Program Index: / Project:
Percentage: / Fund: / Appropriation Index: / Program Index: / Project:
- AUTHORIZATION & COMMENTS/NOTES
Prepared By: / Date: / Comments:
Approved By: / Date:
HR/PAYROLL USE ONLY
HRMS Processor: / SelectCasey KiserJennifer McWaidKellie McClintock / Represented Position: / YES NO / Eligible for Leave Accruals: / YES NO S/L Only
Date Received: / Union: / SelectNot ApplicableCoalitionPTE Local 17SEIU 1199NWTeamsters Local 117WAFWPWFSEWPEA / Periodic Increment:
Date Processed: / Change in CBA: / YES NO / Appt Letter Received: / YES NO
Sent to Payroll: / Received by Payroll: / Processed by Payroll:
**Send completed PPDS to the Small Agency Inbox **
Form Revised 3.13.18
- ACTION INFORMATION
Agency Name:Use the drop-downs to choose your agency name.
Effective Date:The effective date of the action – the first day the employee is in the status. If the action is for a Leave of Absence (i.e. FMLA), enter the first day the employee is considered to be on leave. If the action is a separation, enter the employee’s last day in pay status.
Recruitment #:If this appointment is resulting from a recruitment, enter the recruitment number. If applicable, provide the date the candidate accepted the job offer.
Action Type:The type of action you are requesting. If you need help identifying which action to use, contact your HR consultant.
Action Reason or Separation Reason:The reason for the action you are requesting. If the action type is separation, choose from the bottom drop-down. If you need help identifying which action type to use contact your HR consultant.
Task:Select from the drop-down – if there is no task associated with this action, select Not Applicable from the drop-down. If there is a task, indicate the expected end date of the task chosen in the space provided.
Review Period:Indicate if there is a review period associated with this action. If yes, indicate the length of the review period.
- EMPLOYEE INFORMATION
Last Name:Employee’s last name.
First Name:Employee’s first name.
M/I:Employee’s middle initial.
Employee ID #:Employee’s personnel number, if employee currently works for the state or has in the past. If this is a new hire action, enter the employee’s social security number.
Prior State Service:If the employee associated with this action is new to the agency, indicate whether this employee has prior state service.
Permanent Address:Employee’s permanent address, to include City, State, and Zip Code.
Mailing Address:Employee’s mailing address, to include City, State, and Zip Code. This field only needs to be completed if mailing address is different than permanent address.
Primary Phone:Employee’s primarycontact number.
Alternate Phone:Alternate number the employee can be reached at, if provided, and type of contact number (i.e. cell).
Work Email:Employee’s work email address.
Gender:Indicate employee’s gender.
Date of Birth:Indicate employee’s date of birth.
Marital Status:Indicate employee’s marital status, and the effective date of this status.
- POSITION & ORGANIZATIONAL ASSIGNMENT INFORMATION
Job Class Title:Employee’s assigned Job Class Title.
Job Class Code:Indicate the job class code associated with the employee’s assigned job class.
Working Title:Indicate the position’s working title, if it is different.
8-Digit Position #:Indicate the 8-digit position number this employee is assigned to.
4-Digit Position #:Indicate the 4-digit position number this employee is assigned to.
Status in Position:The employee’s appointment status in the position.
Overtime Eligible:Indicate if the employee is overtime eligible.
L&I Code:Indicate the risk code of the employee’s position.
Duty Station:Indicate the county the employee works in. List the site address.
Use ESS:Indicate whether your agency utilizes ESS for leave.
ESS Leave Approver:Indicate whether the employee will be an ESS Leave Approver in this position. This field is required if your agency utilizes ESS.
Supervisor Name:Indicate who this position reports to.
Supervisor Position #:Indicate the supervisor’s 8-digit position number.
- BASIC PAY INFORMATION
Reason:Select from drop-down - indicate the reason for the salary change associated with this action.
Salary:Indicate the employee’s new salary, to include whether the amount is per year, month, day, or hour.
Band/Range:Indicate what Band (WMS/EMS) or Pay Range the employee is in based on their job classification.
Step:Indicate what Step within the range the employee is being assigned to. This field does not apply if the job classification is EMS or WMS.
Assignment Pay:Indicate if the employee is eligible for assignment pay. Indicate the type of assignment pay if applicable.
Shift Differential:Indicate if the employee is eligible for shift differential pay.
- WORK SCHEDULE INFORMATION
Work Schedule:Choose from the drop-down list what schedule the employee will be working (5/8s, 4/10s, 9/80s, etc). If the employee is hourly, choose 24/7. If the employee’s schedule is not listed, select Other, and then specify what the schedule will be.
Shift Hours:Indicate the employee’s hours of work.
Full-Time/Part-Time:Indicate whether the employee will be working full-time or part-time. If the employee will be working anything less than 40 hours/week, select part-time. If employee is part-time, fill in part-time percentage.
Teleworking:Indicate if the employee will be participating in teleworking.
- BENEFITS
Insurance Eligible:Indicate if the employee is insurance eligible.
Retirement Eligible:Indicate if the employee is retirement eligible.
Eligible for Personal Holiday:Indicate if the employee is eligible for a personal holiday.
Eligible for Personal Leave Day:Indicate if the employee is eligible for a personal leave day.
- BUDGET INFORMATIONComplete all fields that apply. If unsure, work with your assigned budget analyst.
- AUTHORIZATION & COMMENTS/NOTES:
Prepared By:Complete this section with every action. Indicate who completed the PPDS.
Approved By:Complete this section with every action. Indicate who approved the PPDS.
Comments/Notes:Use the Comments/Notes to indicate any additional information necessary to process the action.