HR Action Request Form

Employee Name*

First Middle Initial Last

Campus:*

Employee Hire Date:*

Effective Date of Change:*

Which action are you requesting?*

Disciplinary Action
Special Circumstance (promotion or pay raise)
Status Change
Leave Status
Other

Disciplinary

Disciplinary Action Requested:

List Violated Policy:

Upload Needed Documents:

Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 10 MB.

* Employee Statements * Performance Evaluation * Classroom Evaluation * Previous Write-Ups * Scholarship Agreement (if applicable) * Video Footage * Any other supporting information or evidence

Special Circumstances

Type of Request:

Promotion
Pay Raise

*employee must be in good standing

New Pay Rate:

Title of New Position:

Reason for Promotion:

Upload documents needed for promotion:

Drop files here or

Max. file size: 10 MB.

* Performance Assessment * Classroom Assessment

Upload documents needed for pay raise:

Drop files here or

Max. file size: 10 MB.

* Performance Assessment * Classroom Assessment

Status Change

Type of status change:

Changing to Part Time
Changing to Full Time
Changing to Seasonal
Changing to Sub
New Offer Letter Signed

(select all that apply)

Date of Change:

Benefits Lost:

PTO Accrual Rate:

Leave Status

Type of request:

FMLA
Short Term Disability Claim

Upload documents needed for FMLA:

Drop files here or

Max. file size: 10 MB.

* FMLA Certificate * FMLA Notification

Upload documents needed for FMLA:

Drop files here or

Max. file size: 10 MB.

* STD Claim Form

Leave effective date:

* Submit once all PTO has been exhausted

Return to work date:

* Submit once all PTO has been exhausted

Physician's return to work document:

Drop files here or

Max. file size: 10 MB.

* STD Claim Form

Other

Please provide more details:

Digital Signature

Name of Admin completing form:

First Last

Disciplinary

Special Circumstances

Status Change

Leave Status

Other

Digital Signature

Locations