Required
Information
for
Required
Information
EPA Personnel
Action
EPA/Post
Actions
for EPADoc
Actions
Activate Position Now
Activate When Dept Notifies EPA Coordinator
PERSONNEL ACTION INFORMATION
Position #
(For New Positions - number will be assigned by HR)
New Position
(Non Budgeted)
New Position (Budgeted)Refill Existing
Position
Multiple Hire: # of _____
Action Type:
Salary Adjustment
Title Change
Yes
Waiver Request to be Submitted to OEO:
Administrative, Interim, Honor or Temp Supplement*
Duties Change
No
Name to be submitted on Waiver Request
City, State
EmplID
EmplID_________________Position
Employee Name
College/Division
OUC
Department/Unit
Current Title
Current Job Code
Proposed Title
Job Code
Current Salary or Proposed Salary if New Position
SAAO II
SAAO I
EPA Function:
EPA Category:
Appointment
Budget Line
Instructional
Research
Professional with rank
Professional without rank
Non-Tenure Track Faculty
SPA to EPA Reclassification
Academic Year (9 Month)
Fiscal Year (12 Month)
At Will
Position Number
Tenured/Tenure Track Faculty
Valid NC Driver's
No
Yes
No
License Required No
FTE
Contract
Title,and
Phone,
Email#and
Position # Supervisor
of Immediate Supervisor
Name, Title
Position
of Immediate
Contact Name and Phone #
For Salary Adjustment Only:
Equity
Base Salary Adj
Current Base Salary
Counter Offer
Duties Change
Market/Retention
Current FTE
Proposed Base Salary
Proposed FTE
Increase Amt over current salary
% Increase over current salary
Salary as of 6/30 Previous F/Y
Increase Amt over 6/30 Previous F/Y salary
% Increase over 6/30 Previous F/Y salary
Salary Supplement:
Base Salary (not changing)
FTE Change
Effective Date
Admin Supplement
Temporary Supplement
Supplement Amount
Interim Supplement
Honor Supplement
New Total Salary
Effective Date
Project
Code/Account
Project
Name
Funding Sources
(i.e. grants, receipts,
trust funds, endowments, etc.)
Funding
Percentage
Project ID
Number
State/Non-State
Dollar Amount
State
Non State
Academic to Fiscal year
Fiscal to Academic year
**Check box if there is a change from :
*Supplement will be removed at the end of the administrative, interim, temporary, or honorary appointment period.
Revised:
7/27/12
Revised:
7/26/2012
Revised:
6/19/2012
Revised: 011/8/2011
02/11/2010
Personnel atat919-515-2708
Questions about this form? Contact CALS
EPA Coordinator
919-513-0765
Page
Page11ofof32
Required
Required
Information
for
EPAInformation
Personnel
Action
(continued)
EPA/Post
for EPA
DocActions
Actions (continued)
Position
Description
(Required
for
All
Position
actions)
Please
essential
and
marginal
position
duties.
Include
an
organizational
chart
with
Position
Description
(Required
for
All
Position
actions)
Please
include
and
marginal
position
duties.
Include
anessential
organizational
chart
with
Position
Description
(Required
forfor
New
Position,
Title
Change,
orinclude
Duties
Change
actions
only)
Please
include
essential
and
marginal
position
duties.
Position
Description
(Required
New
Position,
Title
Change,
or
Duties
Change
actions
only)
Please
include
essential
and
marginal
position
Position
Description
(Required
for
New
Position,
Title
Change,
oressential
Duties
Change
actions
only)
Please
include
and marginal
reporting
lines
and
ADA
checklist
(ADA
checklist
not
required
for
Post
Doc
actions).
Please
attach
a copy
of the
proposed
current
job
reporting
lines
and
ADA
checklist
(ADA
checklist
notare
required
for
Post
Doc
actions).
Please
attach
a copy
of the
proposed
andand
current
descriptions
Include
an
organizational
chart
with
reporting
lines.
(Required
for
Title
Change
and/or
Duties
Change
actions
only).
Please
attach
a job
copy
ofathe
proposed
duties.
Include
an
organizational
chart
with
reporting
lines.
(Required
for
Title
Change
and/or
Duties
Change
actions
only).
Please
attach
copy
ofand
position
duties.
Include
an organizational
chart
with
reporting
lines.
(Required
for
Title
Change
and/or
Duties
Change
actions
only).
changes
and
authority
or educational
Please
refer
theGuidelines
link
below
for
descriptions
and
organizational
charts detailing
the job
changes
and
additional
authority
ordetailing
educational
requirements.
Please
refer
to changes
the requirements.
link
below
forto
The
on
organizational
detailing
the
jobcharts
descriptions
job
and
descriptions
organizational
and
charts
organizational
detailing
charts
the additional
changes
and
the
additional
changes
authority
and additional
orrequirements.
educational
authority
or
educational
Please
requirements.
refer
to the
and
current
the
proposed
and
current
Please
attach
a copy
of the
proposed
and
current
descriptions
and organizational
charts
detailing
the
and
additional
authority
orlink
The Guidelines
onStatute
Interpreting
General
Statute
126-5(c1)(8):
Instructional
and
Research
Staff
Exempt
from
the
State
Personnel
Actthe
which
Interpreting
General
Instructional
and
Research
Staff
Exempt
from
State
Personnel
Act
which
further
define
“Instructional”
below
Please
forrefer
The
to
Guidelines
The
Guidelines
on 126-5(c1)(8):
Interpreting
on
Interpreting
General
General
Statute
Statute
126-5(c1)(8):
126-5(c1)(8):
Instructional
Instructional
andthe
Research
and
Research
Staff Exempt
Staff
Exempt
from
the
from
State
the
Personnel
State
Personnel
Actfurther
which
Act
educational
requirements.
define
the “Instructional”
and “Research”
categories.
http://intranet.northcarolina.edu/docs/legal/policymanual/300.2.5_%5BG%5D.pdf
and
“Research”
categories.
which
further
define
the http://intranet.northcarolina.edu/docs/legal/policymanual/300.2.5_%5BG%5D.pdf
“Instructional”
and
“Research”
categories.
further
define
the
“Instructional”
and “Research”
categories.
http://intranet.northcarolina.edu/docs/legal/policymanual/300.2.5_%5BG%5D.pdf
Qualifications - Education, experience, licensure etc. (Required for New Position, Title Change, or Duties Change actions only) Please
indicate required and preferred qualifications:
Department Required Skills
Basis
for Request
- Indicate
basis
for requesting
new position
or theChange,
primary change
that has
occurred in action
the job for
an existing position. Please include changes to
Justification
(Required
forthe
New
Position,
TitleaChange,
Duties
or Salary
Adjustment
only):
organizational and/or business practices that are applicable to this request.
Preferred Years Experience, Skills, Training, and Education
Other Work/Responsibilities
SIGNATURES
Primary Function
of Organizational
Unit - signature)
Briefly describe the function of the organizational unit (3-4 sentences
(information
below will
be used as electronic
Department
Supervisor
Date
ORGANIZATIONAL CHART
An
organizational
Organizational
charts
should include proposed position,
supervisor,
peers and
Initiator
________________________________________
(Dept. Faculty)
________________________________
Date
______________
Department
Headchart MUST be completed and attached.Per
Date
staff.
Please
indicate
position
numbers.
Refer
to
the
Human
Resources
web
site
for
additional
instructions.
Basis for Request - Indicate the basis for requesting a new position or the primary change that has occurred in the job for an existing position. Please include changes to
Dean/Vice Chancellor Final Approval
Date
www.fis.ncsu.edu/hr/classcomp/ochart.asp
organizational and/or business practices that are applicable to this request.
________________________________________________________________________________________________________________
AVC-HR Review:
Date
AMERICANS
WITH
DISABILITIES ACT (ADA) CHECKLIST
Provost Approval
(if required)
Date
An Americans with Disabilities Act (ADA) checklist MUST be completed and attached. Please reference the Americans
with Disabilities Act
Chancellor
Approval
required)
(ADA)
checklist
located(ifon
the Human Resources web site. http://www.ncsu.edu/hr/forms/classcomp/adachk.doc
Date
_________________________________________________________________________________________________________
Primary Function of Organizational Unit - Briefly describe the function of the organizational unit (3-4 sentences
HR/OEO Use Only:
Request Endorsed
Request Revised
Request Not Endorsed Analyst Initials:
SIGNATURES
ORGANIZATIONAL CHART
(information
belowchart
will be
usedbe
ascompleted
electronic signature)
An organizational
MUST
and attached. Organizational charts
proposed position,
EPA Designation
Key: supervisor, peers and
ROP:should include
Salary
Review
and
support
of Resources
Yes
No site for additional instructions.
staff. Please indicate position numbers.
Refer
to the
Human
web
action:
www.fis.ncsu.edu/hr/classcomp/ochart.asp
Initiator
________________________________________ Per (Dept. Faculty) ________________________________ Date ______________
ORGANIZATIONAL CHART
________________________________________________________________________________________________________________
Approved TItle:
Job Code:
An organizational
chartDISABILITIES
MUST be completed
attached.
Organizational charts should include proposed position, supervisor, peers and
AMERICANS
WITH
ACT and
(ADA)
CHECKLIST
staff.
Please indicate
position numbers.
Refer to the Human Resources web site for additional instructions.Americans with Disabilities Act
An
Americans
with Disabilities
Act (ADA)
JCAT
Title: checklist MUST be completed and attached. Please reference the
6-Digit JCAT #:
www.fis.ncsu.edu/hr/classcomp/ochart.asp
(ADA) checklist located on the Human Resources web site. http://www.ncsu.edu/human_resources/forms/classcomp/adachk.pdf
http://www.ncsu.edu/human_resources/forms/classcomp/adachk.pdf
http://www.ncsu.edu/hr/forms/classcomp/adachk.doc
HR/OEO Approval:
Date:
SIGNATURES
AMERICANS
WITH
DISABILITIES
ACT
(ADA) CHECKLIST
(information
below
will be
used as electronic
signature)
E-mail
notification
sent:
An Americans
with Disabilities
Act (ADA)
checklist
MUST Per
be
completed
and ________________________________
attached. Please reference the Americans
with
Disabilities Act
Yes
Initiator
________________________________________
(Dept. No
Faculty)
Date
______________
Date Completed:
(ADA) checklist located on the Human Resources web site. http://www.ncsu.edu/human_resources/forms/classcomp/adachk.pdf
_________________________________________________________________________________________________________
Revised:
7/27/12
7/26/2012
Revised:
3/22/12
Revised:
011/8/2011
Revised:6/19/2012
02/11/2010
CALSCoordinator
Personnel atat919-515-2708
Questions about this form? Contact EPA
919-513-0765
Page 2 of 32
Required
Required
Information
for
EPAInformation
Personnel
Action
(continued)
EPA/Post
for EPA
DocActions
Actions (continued)
Position
Description
(Required
forfor
New
Position,
Title
Change,
oror
Duties
Change
actions
only)
Please
include
essential
and
marginal
position
duties.
Position
Description
(Required
New
Position,
Title
Change,
Duties
Change
actions
only)
Please
include
essential
and
marginal
position
Position
Description
(Required
for
New
Position,
Title
Change,
or Duties
Change
actions
only)
Please
include
essential
and marginal
REQUIREMENTS
AND
PREFERENCES
Include
an
organizational
chart
with
reporting
lines. with
(Required
for Title
Change
Duties
Please
attach
a copy
ofathe
proposed
duties.
Include
organizational
chart
with reporting
lines.
(Required
for (Required
Title and/or
Change
and/or
Duties actions
Change
actions
only).
Please
attach
copy
of
position
duties.anInclude
an organizational
chart
reporting
lines.
for
Title Change
Change
and/oronly).
Duties
Change
actions
only).
Required
work
other
than Mon.
(8am)
-job
Fri.descriptions
(5pm),
specify:
job
descriptions
job
andproposed
descriptions
organizational
and
charts
organizational
detailing
charts
theplease
changes
detailing
andthe
additional
changes authority
and additional
or educational
authority
requirements.
or educational
Please
requirements.
refer to the
and
current
the
proposed
and
current
Please
attach
ahours,
copy
ofifthe
and
current
and
organizational
charts
detailing
the changes
and additional
authority
orlink
below
Please
forrefer
The to
Guidelines
The Guidelines
on Interpreting
on Interpreting
General
General
StatuteStatute
126-5(c1)(8):
126-5(c1)(8):
Instructional
Instructional
and Research
and Research
Staff Exempt
Staff Exempt
from the
from
State
thePersonnel
State Personnel
Act which
Act
educational
requirements.
which
further
define
“Instructional”
and
“Research”
further
define
the
“Instructional”
and(if
“Research”
categories.
http://intranet.northcarolina.edu/docs/legal/policymanual/300.2.5_%5BG%5D.pdf
Required
License
or the
Certification
any,
please
list): categories.
Commercial Driver's
License Required
Yes
No
No
Physical Required
List any other medical/
drug tests required:
Yes
No
No
ADVERTISING
Qualifications - Education, experience, licensure etc. (Required for New Position, Title Change, or Duties Change actions only) Please
Yes
No
No preferred qualifications:
indicate
required and
Yes
Post
on Monster
Post to InsiderHigherEd.com No
No
Monster Posting Category:
InsiderHigherEd.com Category:
Places you would like to recruit other than NCSU website (note, ad must be attached):
APPLICANT DOCUMENTS
(Required
for New
Position,any
Title Change, Duties Change, or Salary Adjustment action only):
IfJustification
you would like
the applicant
to provide
other document(s) for this position besides
the required (Cover Letter, CV, & Contact
Information for References), please specify:
SIGNATURES
Guest User account: (name/NCSU or Other e-mail)
________________________________________
______________________________________
________________________________________
______________________________________
SIGNATURES
________________________________________
(information below will be used as electronic signature)
______________________________________
Initiator
Per
(Dept.
Faculty)
________________________________________
Department
Supervisor
Date
Date
______________________________________
ORGANIZATIONAL CHART
________________________________________
An
organizational
Organizational
charts
should include proposed position,
supervisor,
peers and
______________________________________
Initiator
________________________________________
(Dept. Faculty)
________________________________
Date
______________
Department
Headchart MUST be completed and attached.Per
Date
Search Committee
e-mail)
(information
below willaccount:
be used as(name/NCSU
electronic signature)
staff. Please indicate position numbers. Refer to the Human Resources web site for additional instructions.
Dean/Vice Chancellor Final Approval
Date
www.fis.ncsu.edu/hr/classcomp/ochart.asp
________________________________________________________________________________________________________________
AVC-HR Review:
Date
AMERICANS
WITH
DISABILITIES ACT (ADA) CHECKLIST
Provost Approval
(if required)
Date
An Americans with Disabilities Act (ADA) checklist MUST be completed and attached. Please reference the Americans
with Disabilities Act
Chancellor
Approval
required)
(ADA)
checklist
located(ifon
the Human Resources web site. http://www.ncsu.edu/hr/forms/classcomp/adachk.doc
Date
_________________________________________________________________________________________________________
HR/OEO Use Only:
Request Endorsed
Request Revised
Request Not Endorsed Analyst Initials:
SIGNATURES
(information below will be used as electronic signature)
EPA Designation Key:
ROP:
Salary Review and support of
Yes
No
action:
Initiator ________________________________________ Per (Dept. Faculty) ________________________________ Date ______________
Approved TItle:
Job Code:
JCAT Title:
6-Digit JCAT #:
HR/OEO Approval:
Date:
E-mail notification sent:
Revised:
7/27/12
Revised:
3/14/12
Revised: 011/8/2011
02/11/2010
Yes
No
Date Completed:
CALSCoordinator
Personnel atat919-515-2708
Questions about this form? Contact EPA
919-513-0765
Page
Page 32 of
of 32