Employee Salary, Job Status and Position Change Form

Management Initiated Action

Type of Action:		In-Band Adjustment:
	Temporary Pay		Change in Duties *	Application of KSA’s
	Competitive Salary Offer		Retention	Internal Alignment
	Role Change	* A revised/updated Employee Work Profile is required.
	Does the employee meet performance standards?		Yes	No
NOTE: If employee’s performance rating is “Below Contributor”, no management initiated increase can be awarded.

Role Change
Current Role Title:		Current Role Code:
Requested Role Title:		Requested Role Code:
NOTE: Use this section only for role change. A revised/updated Employee Work Profile is required.

Salary Action Data
Current Salary:	New Salary:	% Increase
Effective Date:	Temporary Pay Expiration Date
Total % of previous in-band adjustments:
NOTE: Maximum annual increase is 10%

Job	Comments:
Business Need




	Describe Organizational requirements that support the mission. Briefly describe the core work functions
Duties and Responsibilities

Employee	Comments
Performance






Relevant Work Experience and Education






Knowledge, Skills and Competencies





Relevant Training Certification and License





Internal Salary Alignment





Current Salary

Market	Comments
Market Availability






Salary Reference Data






Total Compensation




Salary and market data are available from Human Resources

Financial	Comments
Budget Implications






Long Term Impact





Is departmental funding available?

Sources and References

This document is slightly adapted from a document originally written by the George Mason University.

The original document is available as a free download by following this link

HR Platform