Notice of Status Change Form

PHCCLA Registered Apprenticeship Program

notice of status change form

Please complete the following form for any apprentice changing from ACTIVE status to INACTIVE status in the program and for all REINSTATEMENTS.

Apprentice Name: ______Indentured #: ______

Employer: ______

Person Completing this Form: ______

Requested Status Change: SUSPENSION / CANCELLATION / REINSTATEMENT

Please complete the appropriate section below to complete the status change request:

REQUEST FOR SUSPENSION

Suspension Effective Date: ______Wage at time of Suspension: $______/hr.

Is the apprentice in the first 6 months of the program (probationary period)? YES / NO

Have the appeal rights been explained to the apprentice? YES / NO

Suspension requested by: SPONSOR / PROGRAM PROVIDER / EMPLOYER / APPRENTICE

Reason for Suspension (please select one):

ð Disciplinary Action ð Entered Military Service ð Illness

ð Incarcerated ð Injury ð LEAVE

ð Lateness, Missed Classes ð Low Attendance ð Negative Reports from Contractors

ð Personal Hardship ð Poor Performance ð Refused Drug Testing

ð Substance Abuse Rehab ð Theft ð Unknown

REQUEST FOR CANCELLATION

Cancellation Effective Date: ______Wage at time of Cancellation: $______/hr.

Is the apprentice in the first 6 months of the program (probationary period)? YES / NO

Have the appeal rights been explained to the apprentice? YES / NO

Cancellation requested by: SPONSOR / PROGRAM PROVIDER / EMPLOYER / APPRENTICE

Reason for Cancellation (please select one):

ð Discharged/Released ð Entered Military Service ð Illness/Death

ð Lack of Work ð Accepted Other Employment ð Accepted Related Employment

ð Not Attending Related Instruction ð Program Cancelled by Registration Agency
ð Program Cancelled by Sponsor ð Retired / Resigned

ð Transferred to Another Program ð Unsatisfactory Performance ð Voluntary

REQUEST FOR REINSTATEMENT

Reinstatement Effective Date: ______Wage at time of Reinstatement: $______/hr.

Reason for Reinstatement (please select one):

ð Problem Resolved ð Resolved Family Matters ð Resolved Other Issues

ð Sponsor Action ð Unknown

Additional Comments: ______