<p> Revised Feburary 2015 Faculty Practice Group EDB Transaction Request Form (TRF) Employee Name (Last, First Middle Initial) Employee’s Home Address</p><p>Employee’s Contact E-Mail Address Employee’s Home and/or Cell # Supervisor’s Name & Phone # x OHF Appt Dates and Times Cleared Clinic Location Code Work Phone# HBS Approver Yes Century Center_____ No Comm Sites______Background Check Cleared Campus Address Employee # Yes No N/A Work Shift Base Requisition Number Recruiter Recruiter Phone # x 1. HIRE ACTION Effective Date End Date New Hire (Please indicate if employee has supervisory duties Rehire (Please indicate in the comment section if employee Yes No is a UC Retiree UC Transfer without a break in service – Name of UC Campus Transfer from Another Department (Please indicate name of previous dept & EDB contact & ph # in comment section Additional Appointment Dual Appointment 2. CHANGE IN STATUS 3. CHANGE IN BUDGET/TRANSFER Effective Date Effective Date Promotion Lateral Transfer Voluntary Demotion Change of Account No longer Enrolled as a UC Student Add a Cost Center Limited to Career Career to Limited Transfer to Another Department Per Diem to Career (no break in service) Increase % of Time from % to % Career to Per Diem (complete section 4 – separation, requires a Reduce % of Time from % to % break in service) 4. SEPARATION Separation Effective Last Day Worked Last Day on Pay Status Outgoing Intercampus Transfer? Yes No If “Yes”, explain below. Reason for Separation (give specific reason, i.e., layoff, dismissal, probationary release, career to per diem, etc., and attach any appropriate correspondence)</p><p>Personnel Program Appointment Type Student Status Shift Differential PSS Career Not Registered Evening $ MSP Limited Under Graduate Night $ SMG Casual/Restricted Graduate Weekend $ Contract Other UC Campus Certification $ Per Diem (enter type in comments) Charge Nurse Payroll Title Title Code Step & Salary Grade & Salary</p><p>Account Name Account Number Percent of Time</p><p>Comments</p><p>Prepared by Date Extension Approved by Date Extension Please submit this form by e-mail to your HR Representative (EDB Preparer for processing).</p>