Change of Status Request

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FORM HRM-3 (5/2003) Change of Status Request INSTRUCTIONS: 1. This form should be used to report all changes in status including renewals of appointment, changes PAYROLL PER. # in title, changes in salary, changes in obligation, leaves and terminations for all academic, classified and professional staff including Graduate Assistants and Teaching Assistants. ACTION/ REASON 2. See reverse side for detailed directions including definitions, types of changes and required documentation. EMPLOYEE DATA Department Account No. Supervisor / Contact Name Phone No. E-Mail Ad.

Line Number Employee's Name (First Name, M.I., Last Social Security No. Appointment Type Name) [ ] Classified Service [ ] Professional Service [ ] Assistantship CHANGE/RENEWAL OF APPOINTMENT TYPE o Permanent Appointment (Requires Chancellor’s approval for Professional Employees) o Renewal of: o Temporary Appointment o Term Appointment (# of years) from to o Probationary Appointment (for Professional Employees only) o Probation completion (Classified Service only) o No changes in terms of appointment o Change terms of appointment as noted below: CHANGE(S) IN TERMS OF APPOINTMENT Present Title New Title Effective Date Ending Date

Present Salary New Salary

Present Obligation (full-time, part-time %) New Obligation

Other Status (see reverse for types) New Status

LEAVES

 Sabbatical Leave (see conditions on reverse) % of payfrom to  Sick Leave (types of Sick Leave listed on reverse):  FMLA % of payfrom to o Other Leave with full/partial pay (attach justification) % of payfrom to  Leave without pay (see types on reverse) from to o Unauthorized Leave (AWOL) from to TERMINATION/NON-RENEWAL OF APPOINTMENT  Non-Renewal of Term Appointment o Resigned (attach letter) o Termination of Classified Appointment Eff. Date o Non-Renewal of Temporary Appointment o Retired o Other (types on reverse): REMARKS (FOR PART-TIME FACULTY, PLEASE INDICATE COURSE(S) TAUGHT)

POSITION NO. JOB CODE TITLE (MAX.21 POSITIONS) JR.CL. SAL.GRD. N.U. APPT.CODE TRANS. EFF. DATE

PAY BASIS SALARY RATE P.T. % INCR CODE COURSES TAUGHT LAST SEMESTER / CURRENT SEMESTER TRANS. THRU DT.

APPROVALS ADMINISTRATIVE REVIEW Signature by applicants for sabbatical leave Employee ______Date ______agree to conditions shown on the reverse. (Required for Professional Service leave requests) Supervisor/ Department Head ______Date ______Financial Mgmt. & Budget ______

Dean/Asst/Assoc VP______Date ______Human Resources Mgmt.______

VP/ President______Date ______Return all 3 Copies to Human Resources

35 Types of Changes

Change/Renewal of Appointment Type Permanent Appointment: See “Reappointment Procedures” for Professional Employees. Renewal of Temporary Appointment: Indicate beginning and ending dates. Renewal of Term Appointment: Indicate number of years and beginning and ending dates. Probationary Appointment: For Professional Employees who have a change in title. Probation Completion (Classified Service only)

Change Terms of Appointment Change Title, Salary or Obligation: Complete boxes specified for present and new terms. Change Scheduled Hours, Shift and/or Pass Days: Complete boxes for other status and new. Change Line Number: Complete boxes for other status and new or use Remarks if already used. Change Department, and/or Account/Funding Source: Use Remarks section. Change Supervisor: Complete boxes for other status and new or use Remarks if already used. Change Personal Information (Name, SSN, Address, Other): Use Remarks section.

Leaves Sabbatical Leave at Full Pay (Limited to one semester): See conditions below. Sabbatical Leave at Half Pay (Up to one year): See conditions below. (1 ) (2) Applicants are required to acknowledge an obligation to return to the University at Albany for a minimum of one year at the conclusion of their leave. Where justified, the President may request a waiver of this condition, which must be reviewed and approved by the Chancellor. (3) (4) All changes to an approved sabbatical plan must be approved, in writing, by the appropriate campus officer as soon as such need is known. At the University at Albany this will be the Vice President for Academic Affairs. (5)

(6 In the event of illness or other unplanned circumstances that interrupt an approved ) sabbatical, the faculty member will be placed on another leave as appropriate, when in the discretion of the President such action is in the best interest of the University and the Sick Leave from Sick Leave Accruals: Attach Physician’s statement. Sick Leave with Full or Partial Pay (After exhaustion of accruals): Indicate percent of pay. Sick Leave without Pay: Indicate if pursuant to Family and Medical Leave Act. Other Leave with Full or Partial Pay: Requires Chancellor’s approval for Professional Service. Leave without Pay: Indicate purpose of leave including probationary leave or child care. Unauthorized Leave (AWOL): Attach explanation for action.

Termination/Non-Renewal Non-Renewal of Term Appointment: Indicate effective date. Non-Renewal of Temporary Appointment: Indicate effective date. Resigned: Attach resignation letter and indicate if resigning to accept other State employment. Retired (Must apply to appropriate retirement system to begin collecting retirement benefits). Termination of Classified Service Appointment: Indicate effective date. Termination/Leave (Classified Service only): Also complete leave without pay section. Deceased: Check box for other and indicate date and time (if known) of death.

Approvals Only Supervisor/Department Head approval required for change in scheduled hours, shift and/or pass days, sick leave (Classified Service) and AWOL. Leaves for Classified Service employees are not requested but are reported.