Appendix A
Pay Action Worksheet
1. TYPE OF ACTION (Check Only One)
 ESTABLISH POSITION
IN-BAND ADJUSTMENT
 CHANGE IN DUTIES
 APPLICATION OF NEW KNOWLEDGE, SKILLS,
ABILITIES, COMPETENCIES FROM EDUCATION,
CERTIFICATION, LICENSURES, ETC.
 RETENTION
 INTERNAL ALIGNMENT
 STARTING PAY
 PROMOTION
 VOLUNTARY TRANSFER
 VOLUNTARY DEMOTION
 TEMP PAY
ROLE CHANGE
 UPWARD
 DOWNWARD
 LATERAL
 COMPETITIVE SALARY OFFER
 DISCIPLINARY OF PERFORMANCE RELATED
 RECOGNITION AWARD
1. IDENTIFYING INFO & SALARY ACTION DATA
CANDIDATE/EMPLOYEE NAME
SOCIAL SECURITY NUMBER
CURRENT AGENCY CODE
NEW AGENCY CODE
CURRENT POSITION #
NEW POSITION #
CURRENT ROLE CODE/ROLE TITLE
NEW ROLE CODE/ROLE TITLE
CURRENT PAY BAND
NEW PAY BAND
CURRENT SOC CODE/SOC TITLE
CURRENT WORK TITLE
NEW SOC CODE/SOC TITLE
NEW WORK TITLE
CURRENT ORGANIZATIONAL UNIT
NEW ORGANIZATIONAL UNIT
1. PERFORMANCE
Does this employee meet
performance standards?
CURRENT
LOCATION CODE
CURRENT FUNDING
NEW LOCATION
CODE
NEW FUNDING
 YES
 NO, (If employee’s performance rating is “BELOW CONTRIBUTOR”, no
management initiated increase can be awarded.)
1. All salary actions require the consideration of the following pay factors:
Duties and responsibilities
FOR NEW EMPLOYEE, DESCRIBE KEY DUTIES WHICH LINK TO THIS PAY ACTION
FOR CURRENT EMPLOYEE, SUMMARIZE JOB DUTY CHANGES
CHANGE IS:  PERMANENT
 TEMPORARY
Internal salary alignment
ARE THERE OTHER EMPLOYEES AFFECTED?  YES  NO
INEQUITY (%) WITH OTHER CLOSEST COMPARABLE EMPLOYEES.
Knowledge, skills, abilities, competencies
FOR NEW EMPLOYEE, DESCRIBE RELEVANT EXPERTISE, BEHAVIORAL FACTORS.
FOR CURRENT EMPLOYEE, DESCRIBE INCREASE IN RELEVANT TECHNICAL EXPERTISE, BEHAVIORAL
FACTORS
Relevant work experience and education (SUMMARIZE EMPLOYMENT HISTORY & ACADEMIC CREDENTIALS)
HOW DOES THIS APPLY TO JOB ASSIGNMENTS?
Relevant training, certification, license, etc. (LIST SPECIALIZED COURSES OF INSTRUCTION, CERTIFICATION,
LICENSURE)
HOW DOES THIS APPLY TO JOB ASSIGNMENTS?
Agency business need (DESCRIBE ORGANIZATIONAL REQUIREMENTS FOR THE WORK)
Budget implications (DESCRIBE SHORT & LONG TERM FISCAL CONSEQUENCES)
Market data (IDENTIFY DATA USED & SOURCE OF DATA)
Total compensation (FOR NEW EMPLOYEES INCLUDE CASH COMPENSATION & AVERAGE % VALUE OF BENEFITS
PACKAGE)
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Long-term impact
Market availability DIFFICULTY IN RECRUITING?
 NO
 YES (IF YES, PROVIDE EXPLANATION)
OTHER JUSTIFICATION FOR ACTION REQUESTED. ATTACH ADDITIONAL INFORMATION, AS NECESSARY
1. INFORMATION FOR COMPETITIVE OFFER
Describe the following
 Documentation of actual salary offer
 Criticality of retaining the employee
 Impact on agency operations should the employee leave
 Difficulty in replacing the employee’s knowledge, skills, abilities, competencies
1. INFORMATION FOR IN-BAND ADJUSTMENT
TOTAL % OF PREVIOUS IN-BAND ADJUSTMENTS (INCLUDING LATERAL ROLE CHANGE INCREASES) THIS
FISCAL YEAR
1. INFORMATION FOR RECOGNITION AWARD
AMOUNT OF
TOTAL AMOUNT
RATIONALE FOR RECOGNITION AWARD
AWARD
OF RECOGNITION
AWARD THIS
FISCAL YEAR
1. SALARY ACTION DATA
CURRENT SALARY
PERCENTAGE OF
INCREASE/DECREASE
REQUESTED
NEW SALARY
SUPPLEMENTAL PAY
EXPIRATION DATE
PLEASE ATTACH A REVISED EMPLOYEE WORK PROFILE (EWP), IF CHANGED.
ADDITIONAL COMMENTS:
DEPARTMENTAL AUTHORIZATION:________________________
DATE:_____________
ADMINISTRATION AUTHORIZATION:_______________________
DATE:_____________
HR AUTHORIZATION:____________________________________
DATE:_____________
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