Appointment/Status Change Recommendation Form
AMENDED / (BOB) Payroll Effective Date
-- / (Pick One)Non VeteranDisabled VeteranDisabled Viet Nam VeteranNYS Disabled Viet Nam VeteranNational Guard (active)Active Reserve of any Military BranchVeteranViet Nam Era Veteran (1/1/63-5/7/75)NYS Viet Nam Era Veteran (1/1/63-5/7/75)
Salu, First Name, MI, Last Name / * SSN - Last 4 Digits Current/ Returning Employees
*Full SSN New Employees / Date of Birth (DOB) / Military Status:
(Pick One)Allen AdminBrown BuildingChapman BldgCommissaryCooper HallDailey HallDrake LibraryEdwards HallEOCHartwell HallHazen HallHolmes HallLathrop HallLennon HallLiberal ArtsMetroCenterMorgan IIIRakov CenterSERCSeymour UnionSmith HallTowerTuttle NorthTuttle South
Street, City, State, Zip / Room # / Building / Office Telephone / Home Telephone
Retired Public Employee? Yes No / If yes, date of retirement / Retirement System: (Pick One)TIAA-CREFTRSERSINGMet LifeValic

* All Previous or Current Status * Only New Appointee/New Status

Department:
Budget Title & Grade:
Local Title & Grade (if different):
Appointment Type: / Adm AptAdm DesgnContingent PermContinuingExtra ServicePermanentProbationaryProvisionalTemporaryTermVolunteerXtraSrv / Adm AptAdm DesgnContingent PermContinuingExtra ServicePermanentProbationaryProvisionalTemporaryTermVolunteerXtraSrv
Supervisor’s Name:
Obligation (CalYr/ AcaYr/ ColYr): / AcaYrCalYrColYrSummer SessionWinter SessionOther / AcaYrCalYrColYrSummer SessionWinter SessionOther
Employee Obligation to Dept. (dates) / - / -
Salary Basis (Ann/ Sem/ Biw/Hry): / AnnBiWFeeHRYOtherSemStipendXtraSrv / AnnBiWFeeHRYOtherSemStipendXtraSrvN/A / AnnBiWFeeHRYOtherSemStipendXtraSrv / AnnBiWFeeHRYOtherSemStipendXtraSrvN/A
Salary/Stipend:
Payroll End Date (Required for Term, Temp & Adm Designations (COB):
Full-time/Part-time/Percentage / Full-Time Part-Time %
/ Full-Time Part-Time %
Part-time must complete: / Hours Per Week Worked / Hours Per Week Worked

Weekly Work Schedule

/ Su / Mo / Tu / We / Th / Fr / Sa / Su / Mo / Tu / We / Th / Fr / Sa
Full-time Classified Staff: Indicate Shift / (Pick One)5:00 am - 1:30 pm6:00 am - 2:30 pm6:30 am -3:00 pm7:00 am - 3:00 pm7:00 am - 3:30 pm7:30 am - 3:30 pm7:30 am - 4:00 pm8:00 am - 4:00 pm8:00 am - 4:30 pm8:30 am - 4:30 pm9:00 am - 5:00 pm3:00 pm - 11:00 pm3:00 pm - 11:30 pm4:00 pm - 12:00 am5:00 pm - 1:30 am10:30 pm - 7:00 am11:00 pm - 7:00 am / (Pick One)5:00 am - 1:30 pm6:00 am - 2:30 pm6:30 am -3:00 pm7:00 am - 3:00 pm7:00 am - 3:30 pm7:30 am - 3:30 pm7:30 am - 4:00 pm8:00 am - 4:00 pm8:00 am - 4:30 pm8:30 am - 4:30 pm9:00 am - 5:00 pm3:00 pm - 11:00 pm3:00 pm - 11:30 pm4:00 pm - 12:00 am5:00 pm - 1:30 am10:30 pm - 7:00 am11:00 pm - 7:00 am
Funding Source (Accounts):
Courses (*Part-Time Only)
# = number of courses
list = list the courses and credit hours
Use Notes/Comments box if necessary / Fall: # list
Winter: # list / Fall: # list
Winter: # list
Spring: # list
Summer: # list / Spring: # list
Summer: # list
Leaves: / (Pick One)Child RearingDisabilityDrescherEducationFMLALWOPMaternityMilitaryOtherSabbaticalSickWrkReductTitleF / Yes No / (Pick One)100% = 100% Salary75% = 75% Salary50% = 50% Salary25 % = 25 % Salary0% = 0% SalaryOther - Please Fill in
Type of Leave / FMLA eligible / Leave Begin Date / Leave End Date / Leave Salary Percent %
Return from Leave:
Effective Date
Separation: / (Pick One)DeathDisabilityEndTempResignRetireEnd Admn Dsgntn NonRenewCancel ApptOther - See NotesTransfer Out
Last Day Worked (COB)
OLD / NEW / (HR Office Use Only) Clssfd Info
To:
From:
____Attach original resume/canvass
____Addt’l position requirements (license,etc) / Sent to
Supervisor:
____Orient.
√ List
____Perf.
Plan
____Prob.
Memo / CSClr#______Serial # ______
CSClr Valid Through 1)______
2)______
Serial/Cert#______Score______
Title/Status______
Item#
PR Mode
Neg. Unit / PR Min:______PR Max:______
Final Approvals: ______
SUNY HR Date Letter Date
______
Unit Head Date HR/AAO Date Letter Type
______
Dean/Dir Date President Date Payroll Date
______
VP Date NYSTEP Date ______
requested processed Payroll # / Notes/Comments:
See Attached New Faculty Appt. Offer Summary