University Human Resources
Pay Action Request Form
For Classified Employees and University Staff
I. School/Department Information
Organization Name:
/Organization Code:
Contact Person:
/Email:
Phone:
/Fax:
Department/Program Head’s Name
/SignatureNOTE: Approval Signatures must be documented in Section V.
/Date
II. Employee Data
Employee Name: ______
/Employee ID#: ______
Role Title:
/Work Title:
Position #:
/Assignment #:
/Salaried
/Hourly
/%FTE
/(If different from Employee ID #)
lII. Reason for the Request (See the “Guide to Preparing Pay Action Requests for Classified Employees and University Staff”: tp://www.hrs.virginia.edu/compensation/classification/guidetoparf.html )
NOTE: One request per form. Please select either ONE In-Band Pay Adjustment or ONE Other Pay Action Request.Type of In-Band Adjustment (IBA): (Select only one) NOTE: IBAs cannot be used to provide internal counteroffers.
Application of New Knowledge, Skills, Abilities, and/or Competencies from Education and/or Training
Change of Duties and Responsibilities
Internal Salary Alignment
Retention
Select Method of Payment:
Base Salary Adjustment OR One-time Payment (Non-base adjustment)
Other Pay Action Request:
Temporary Pay (“Acting Pay” in Oracle/HRMS)
Competitive Salary Offer NOTE: Cannot be used to provide internal counteroffers.
Current Salary: $
/Requested Salary: $
/Effective Date:
Amount of Requested Increase: $
/Percent of Requested Increase:
/Expiration Date:
/(Applies to Temporary Pay Only)
List all previous IBAs received by this employee (if any). Include effective date, IBA type, & percentage increase:
Will this pay action, if approved, create adverse impact to other employees in the School or Dept? No Yes**If “Yes”, provide full explanation. Attach IBA-Internal Salary Alignment Data Template located at tp://www.hrs.virginia.edu/compensation/classification/inbandtemplate.xls identifying impacted employees.
University Human Resources (UHR Use Only)
Effective Date: Pay Action Expiration Date: ______Role Code: Pay Band: ______
Current USC: New USC: If Non-Exempt (√): ______
Salary Info: Current: New: Amount of Increase: % of Increase:
Note to UHR Employee Records:
______
UHR Reviewed by: Date: Keyed by Emp Records: Date:
*Special Authorization (Provide UHR Name/Title): rev 08/08/06
Questions regarding the use of pay practices should be directed to your respective School or Department Human Resource Office or to central University Human Resources Office of Compensation Management at 924-4747/4366 or 243-2204/2206.
IV. Required Pay Factor Documentation
A. Performance-- The requesting manager confirms that the employee’s performance is at least at the “Contributor” level (meets expectations/satisfactory) in all job elements/core responsibilities.
/YES
B. Organizational Business Need (Describe how the primary responsibility of the position contributes to overall success of the organization.)C. Budget Acknowledgement (The requesting manager confirms funding is available to support this pay action request for its duration if approved.)
Funding Is Available for this Pay Action Request /YES
D. Justification Detail/Required attachments for all pay action requests:1. Justification Details – Provide your business justification for this request as a one page or less attachment. (See the “Guide to Preparing Pay Action Requests for Classified Employees and University Staff”)
2. A current Employee Work Profile/Parts I and II only (Please circle on the EWP any added/changed job duties, if relevant).
3. A current Organization Chart (Please circle the employee’s name being recommended for a pay increase).
Ø In addition, proposals for IBAs due to “Internal Salary Alignment” should include the IBA-Internal Salary Alignment Data Template.
Ø In addition, proposals for “Competitive Salary Offers” must include a copy of the external offer letter.
V. Authorizing Signatures
Authorizing Officials: Please indicate your decision regarding this pay action request by providing your signature below: / Approved Salary (if modified from proposed) / Deferred?(√ if “Yes”) / Not Approved?
(√ if “Yes”)
Compensation Management Advisory Committee Recommendation (If applicable. Usually refers to IBAs)
______
Print or Type Name of Recommending Official
______
Signature / $ ______
Dean/Department Head Reporting to Vice President**(Required for all pay actions requested)
______
Print or Type Name
______
Authorizing Signature / $ ______
**Note: Please forward completed form to UHR Office of Compensation Management. Regarding IBAs only: UHR will review IBA requests received from Deans/Department Heads prior to review and action by respective Vice Presidents. UHR will forward IBAs to respective Vice Presidents.
Vice President (Required for IBAs; may include other pay actions.)
______
Print or Type Name
______
Authorizing Signature / $ ______
Note: Completed form and required attachments should follow the internal routing procedures established within each School or Department first. Then forward completed Pay Action Request Form and required attachments to UHR Office of Compensation Management. Messenger mail address: P.O. Box 400127, Michie South. Physical Location: 914 Emmet St.