Payroll Status Change
Employee Name:
Full Name
Position Was:
Position Updated to:
Home Facility Was:
Home Facility Change to:
Add Facility In Active Patient Report:
Remove Facility In Active Patient Report:
Status Was:
Full Time 40
Full Time 30
Part Time
Per Diem
Traveler (int)
Clinical Champions Level 1
Clinical Champions Level 2
Clinical Champions Level 3
Committed PRN
Status Change to:
Full Time 40
Full Time 30
Part Time
Per Diem
Traveler (int)
Clinical Champions Level 1
Clinical Champions Level 2
Clinical Champions Level 3
Committed PRN
Old Hourly:
New Hourly:
Old Salary:
New Salary:
Termination Date/Last Day Worked (please use calendar icon to enter the date)
-
Month
-
Day
Year
Use this field to input the final day worked for a full or part-time employee.
Why is the change taking place? (i.e. positive annual review, employee resigned, move from full/part time to on-call, etc.)
Effective Date of Change/First day PRN (you must use the calendar icon to enter the date):
-
Month
-
Day
Year
For an employee moving from full/part-time to per diem, effective day is the day following the last day worked as regular employee.
To help ensure we are competitive in the job market, please answer the following questions in case of a regular employee termination or regular to PRN status change:
Who is the terminating employee's new employer?
What is their new job title?
What is the setting of their new position?
What is their new hourly wage or salary?
Are there any other details relevant to their termination or new employment that should be noted?
Authorization:
Name:
*
Title:
*
Date
-
Month
-
Day
Year
Date
Fax back-up documentation to 888-522-4571.
Comments:
Submit
Should be Empty: