Confidential Employee Records EMPLOYEE NAME LAST FIRST MIDDLE EMPLOYEE PAYROLL EMPLOYMENT TYPE PART TIME FULL TIME SEASONAL TEMPORARY EDUCATIONAL CO-OP SECURITY CLEARANCE LEVEL DATE GRANTED YEARS OF SERVICE 1 2 3 4 5 6 7 8 18 9 10 19 20 11 12 HIRE DATE 13 14 15 16 17 BENEFIT ELIGIBILITY DATE / PAYROLL DATA MARITAL STATUS NAME OF SPOUSE / / / / / BIRTH DATE SEX SOCIAL SECURITY NUMBER NO. OF DEPENDENT CHILDREN / DATE / FEDERAL WITHHOLDING EXEMPTIONS CLAIMS ADDITIONAL WITHHELD AMOUNT STATE TAX CITY TAX INSURANCE INSURANCE DATE ELIGIBLE DATE JOINED DATE WITHDRAWN BENEFITS BENEFITS DATA DATE ELIGIBLE DATE JOINED DATE WITHDRAWN LIF E MEDICAL SELF UNION STATUS PENSION PLAN MEDICAL DEP. CREDIT UNION MAJ. MED. SELF COBRA COMPLIANCE INFORMATION BENEFITS ENDING FACES EMPLOYER MAJ. MED. DEP AD & D SELF / / / ACCEPTED REJECTED / / / NO RESPONSE AD & D DEP COBRA DENTAL SELF DATE EMPLOYEE NOTIFIED DENTAL DEP. EMPLOYEE ACCEPTED REJECTED CHANGE OF ADDRESS DATE ADDRESS CITY STATE ZIP TELEPHONE ( ) R - DATE ADDRESS CITY STATE ZIP TELEPHONE ( ) R DATE ADDRESS CITY STATE ZIP TELEPHONE ( ) R DATE ADDRESS CITY STATE ZIP TELEPHONE ( ) R - EMERGENCY INFORMATION IN EMERGENCY NOTIFY RELATIONSHIP CITY STATE ZIP TELEPHON E ( ) TELEPHON E ( ) R R - POST-EMPLOYMENT EDUCATION OR TRAINING DATE SCHOOL/LOCATION TYPE OF TRAINING DEGREE DIPLOMA DATE SCHOOL/LOCATION TYPE OF TRAINING DEGREE DIPLOMA DATE SCHOOL/LOCATION TYPE OF TRAINING DEGREE DIPLOMA SEPARATION RECORD DATE REASON RESIGN ACTION DISMISSAL RECOMMENDED FOR RE-EMPLOYMENT / / REASON YES NO 2001 © American LegalNet, Inc. Evaluations/ Warnings WARNINGS DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE / / EVALUATIONS / CODE / CODE / CODE / CODE / CODE / CODE / CODE / CODE / CODE / CODE DATE / / / CODE / CODE / CODE / CODE / CODE / CODE / CODE / CODE / CODE / CODE DATE / / / CODE / CODE / CODE / CODE / CODE / CODE / CODE / CODE / CODE / CODE / / DATE DATE / / DATE DATE / / / / / / / / / / DATE DATE / / DATE DATE / / / / / / / / / / DATE DATE / / DATE DATE / / / / / / / / / / DATE DATE // / // / DATE DATE / / / / / / / / DATE / / DATE / / A = END OF PROBATION B = MERIT C = ANNUAL REVIEW E = OTHER 1. D = PROMOTION 3. 2. 4. Confidential Wage / Salary History POSITION AND CLASSIFICATION FROM TO WORK LOCATION/DEPT RATE OF PAT AMOUNT PER REASON FOR CHANGE* *A: BEGINNING EMPLOYMENT B: END OF PROBATION C: MERIT D: ANNUAL REVIEW E: PROMOTION F: TRANSFER G: PAY GRADE ADJUSTMENT/ UNION SCALE H: COST OF LIVING I OTHER 1. 3. 2. 4. 2001 © American LegalNet, Inc. PUE17 2 FL2G, Other Information TOPIC COMMENTS (INCLUDE DATE AND -SIGNATURE) ~U517 S F~ 2001 © American LegalNet, Inc.
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