REQUEST FOR PERSONNEL ACTION

DALLAS COUNTY, TEXAS

FULL NAME	ASSIGNMENT #
SOC SEC #	DATE OF BIRTH
SEX	M F	MARITAL STATUS	M S D

DEPARTMENT NAME: NO	DEPARTMENT NAME: NO

CURRENT	EFFECTIVE DATE	PROPOSED
GRADE	GRADE
JOB CODE	JOB CODE
JOB TITLE	JOB TITLE
POSITION NO.	POSITION NO.
SALARY MONTHLY	SALARY MONTHLY
SALARY HOURLY	SALARY HOURLY

BI-WEEKLY	LONGEVITY	BI-WEEKLY	LONGEVITY
BI-WEEKLY	SITE DIFF	BI-WEEKLY	SITE DIFF
BI-WEEKLY	SDP	BI-WEEKLY	SDP
BI-WEEKLY	OTHER	BI-WEEKLY	OTHER

STATUS

FULL TIME	PART TIME	REG	TEMP	NEW HIRE	RE-HIRE

ACTION

ADJUSTMENT (To start/stop Site DP and SDP)	LEAVE OF ABSENCE (LOA)
COST OF LIVING INCREASE	MERIT INCREASE
DEMOTION	PROMOTION
FMLA – INTERMITTENT	STEP INCREASE
FMLA – STANDARD	LATERAL TRANSFER
FMLA – ACTIVE DUTY	RETURN – FMLA
FMLA – INJURED SERVICEMEMBER	RETURN – LOA
JOB RECLASSIFICATION	RETURN – MILITARY

RACE

WHITE	BLACK	HISPANIC	AMERICAN INDIAN	OTHER

PERSONAL DATA CHANGES

ADDRESS	MARITAL STATUS	NAME
OLD	NEW
NAME
STREET
CITY
ZIP CODE
TELEPHONE NUMBER – HOME
MARITAL STATUS

OFFICIAL OR DEPARTMENT HEAD:

DATE SUBMITTED: