Personal Data	Work Data	Time & Attendance
EMPLID

Name

SSN

DOB

Race	Sex

Address

City

State	Zip

Home Phone

Effective Date

Job Title

Job Code	Gr	St

Position#	Salary Plan

Hrly Rt	Annual Rt

Class Indc	Incen

Dept.

Acct Cd

Location Cd

Work Address

Work Phone

Email Address	Bar Code

Approver ID

Timekeeper ID

Profile Type (Check One)

Approver Timekeeper View Only (Empl)

Empl Lunch (0,30,45,60)

Sign-on Method (Check one)

Desktop Clock Swipe Clock Bio

Tele Access
Department Use Only (fill-in or check changed items)
Effective Date:	/	/
New Hires	Leaves	Moves	Separations	Miscellaneous
31 Unclassified

32 Classified

33 Re-employ

34 Mayoral Appt	20 Military

21 Active/Mil

23 Suspension

Working Days

Suspension End Date

24 Sick

25 FMLA

26 Education

27 Worker’s Comp

28 Other

29 Return from Lv	41 Promotion

42 Transfer

43 Reassign

44 Demotion

45 RTFC

481 Fire 40to53 hrs

482 Fire 53to40 hrs	12 Resign Good Std

15 Resign Bad Std

12A Resigned

14 Dismissed

16 Terminated

18 Retired

19 Deceased

27S Worker’s Comp Settlement --DNR	71 Reinstate CSB wo/pay

72 Reinstate CSB w/pay

73 Rescinded by Dept

74 Rescinded by Empl

81 Status Change

86 Name/Address Chg

87 Reprimand

99

Specify
Salary Changes
54 Education/ Experience /

Other Special Pay

55 Upgrade

69 Grade Change

99 Higher Step Auth (Ord)

Other
3rd Digit Codes	Position Changes

0 Mayoral Moves

1 Temp Not Qual

2 Move to Perm

3 Incr Control Date Changed

4 Provision

5 Xtra Help

6 Other

7 Qual Temp

8 Title Change

9 Seasonal	Class Unclass FOC Yes No
New Position Title

Position#	Job Code

Fund	Account

Center	Loc Cd

Wk Address

Approver ID

Timekeeper ID

Profile Type (Check One)

Approver

Timekeeper

View Only (Empl)	Empl Lunch (0,30,45,60)

Sign-on Method (check)

Desktop	Clock Bio

Clock Swipe	Tele Access
COMMENTS:
Human Resources & Employee Benefits Use Only
Benefit Info	Payroll Info	Pension Info
___ 40 No Benefit	___ 50 Sick Lv., Vac, Incr.

___ 41 Health & Life	___ 55 Medicare

42 Pen-Health – Life	___ 60 All Benefits

___ 65 Continuation of Health Benefits

Wait 90 days	Grade	Step

Hr/Day/Rate

Standard Gross

Annual Salary

Incre. Contr. Date Change

(Check one) Yes No	Pension Fund

Hospital Co.

Life Company

Pension Plan

Mar. Status/Date
_ First City Emp. Date

Current City Emp. Date

Empl Current Position No.
IF PREVIOUS CITY EMPLOYEE
Title

From Date	To Date

Grade	Step
____________________________/_________ Employee Signature/ Date

____________________________/_ _______ Immediate Supervisor/Date

____________________________/_ _______ Bureau Head/Date	___________________________/___________ Form Completed By/Date

___________________________/___________ Certified by/Date

__________________________/____________ Dept. Head/Date

HR TURNAROUND DOCUMENT AND CERTIFICATION FORM (TAD)

HR Revision 1 8/2005

Personal Data

VLivsey

2006-03-15

DPHR