HILL HEALTH CENTER
HUMAN RESOURCES DEPARTMENT
PAYROLL CHANGE DATA FORM
To: The Payroll Department
From: _______________________________________________________ Dept.,
___________________________
Date: ________ / ________ / 2003
Please
make the following Employee Payroll changes:
Employee’s
Name: ______________________________________________
Dept., _______________________
Effective
Date: ________ /
______ / 2003
Original
Date of Hire: ________/_________/
________
THE
CHANGE (S)
___________________________________________________________________________________________________________
Check
All Applicable Boxes From To
___________________________________________________________________________________________________________
( )
Department
___________________________________________________________________________________________________________
( )
Job Title
___________________________________________________________________________________________________________
( )
Shift
___________________________________________________________________________________________________________
( )
Rate
___________________________________________________________________________________________________________
( ) Assorted
Payroll Ded.
i.e.
Ins. Additions/subtractions
___________________________________________________________________________________________________________
REASON
(S) FOR THE CHANGE (S)
( ) Demotion ( ) Resignation Insurance
Changes:
( ) Discharge ( ) Structural Increase ( ) Add spouse
only
( ) General Wage Increase ( )
Transferred ( ) Add family coverage
( ) Lay Off ( ) Other ( ) Health
( ) Leave of Absence
____________________ ( ) Dental
( ) Merit Increase ( ) Dep. Life
( ) Promotion
_______% Effective
Date ____ /____ /2003
Requested
by:
______________________________________________ Date: _______/
_______/2003
Department Head Signature
Change
Authorized by: ___________________________________________________ Date:
_______/ _______/2003
Charles B. Rose, Assoc. Dir./Finance
Budget
Verification - Grants: ____________________________________________ Date: _______/ _______/2003
Dir.
of H.R - Andrea Lobo-Wadley: ________________________________________ Date:
_______/ _______/2003