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ACTIVE
E CLASS COMPENSATION
BENEFITS EMPLOYMENT
7. APPROVALS HR USE ONLY
EFFECTIVE DATES6.5. COMMENTS
SALARY COMPONENTS (Whole Dollars/Full-Time)
Timesheet Organization
3. CURRENT EMPLOYEE STATUS (Check one from a, b, and c.) INSTRUCTIONAL EMPLOYEES ONLY
2. REASON FOR ACTION (Check all that apply.)
b.d. Check if applicable.c.a.
AddressStreet City State Zip
J# J
SS# (last 4 digits)Middle InitFirstLast
Name1. EMPLOYEE INFORMATION
YES NO
YES NO
Revised 01/02/19
SALARY COMPONENTS (Whole Dollars/Full-Time)
Timesheet Organization
INSTRUCTIONAL EMPLOYEES ONLYd. Check if applicable.
4. PROPOSED EMPLOYEE STATUS (Check one from a, b, and c.)b. c.a.
RETIRED
TOTALS
UNIVERSITY OF SOUTH ALABAMA
PERSONNEL ACTION FORM This form must be completed in Adobe.
BANNERFUND ORGN ACCT PROG
% EMP SALARY
DOLLAR AMOUNT
TOTALS
DOLLAR AMOUNTPROGACCTORGNFUND
BANNER % EMP SALARY
USA HEALTHCARE MANAGEMENT, LLCUNIV OF SOUTH AL HEALTH CARE AUTHORITY
ASST. VP, HUMAN RESOURCES DATEDEAN / HOSP ADMIN DATE
DEPARTMENT HEAD/CHAIRPERSON DATE BUDGET OFFICE DATE
DIRECTOR/SUPERVISOR DATE
Date Prepared
PTRJCRE
Out of Class
Out of Class
PRESIDENT / DIVISION HEAD DATE
Contact PersonTelephone
Appointment
Salary ChangePromotion
ResignationRetirementTermination
LayoffTransferOne Time Payment
Labor Distribution Change
Other
RegularTemporary
Full-timePart-time
FacultyCoach
AdministrativeStaff ExemptStaff Non-Exempt
Contract (Non-Faculty)
9 month
12 month
Other
Temporary Faculty
Position # Position Title Position ClassDepartment/Unit NameFTE Total Annual Full-Time Salary Hourly Rate
BASE
STIPEND
DEGREE
LPN
CLN LVL
ACLS/EQUIV.
NATL CERT
CHARGE
OTHER
One-Time Payment
RegularTemporary
Full-timePart-time
FacultyCoach
AdministrativeStaff ExemptStaff Non-Exempt
Contract (Non-Faculty)
9 month
12 month
Other
Temporary Faculty
Position # Position Title Position Class
Department/Unit NameFTE
BASE
STIPEND
DEGREE
LPN
CLN LVL
ACLS/EQUIV.
NATL CERT
CHARGE
OTHER
One-Time PaymentHourly RateTotal Annual Full-Time Salary
EFFECTIVE DATE END DATE
