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KITTITAS COUNTY PERSONNEL ACTION FORM (PAF) <br />Updated: 04/08/11 FOR HR USE: NT Update Eval Date EvalRating(IE—ID—S—AA—S) Initial <br />SECTION 1: EMPLOYEE DATA <br />LAST NAME <br />Roth <br />f FIRST NAME <br />I Tim <br />EMPLOYEE # <br />R1167 <br />EFFECTIVE DATE <br />01/01/2017 <br />SECTION 2: TYPE OF ACTION <br />EMPLOYEE TYPE <br />EMPLOYEE ACTION <br />TYPE OF SEPARATION <br />REASON FOR SEPARATION <br />❑✓ FULL-TIME (1) <br />❑ PART-TIME (2) <br />❑ LIMITED PART-TIME (3) <br />❑ TEMPORARY (4) <br />❑ CASUAL (5) <br />❑ SEASONAL (6) <br />❑ PROJECT (7) <br />❑ WORK STUDY (8) <br />❑ VOLUNTEER (9) <br />❑ NEW HIRE <br />❑ RE -HIRE <br />❑ MERIT/ STEP <br />❑ POSITION CHANGE (Describe Below) <br />❑ BUDGET CHANGE (Describe Below) <br />❑ LEAVE (List Type Below) <br />❑ TERMINATION (Provide Separation Info) <br />'I�L?THER (Describe Below) <br />❑ DISCHARGE (D) <br />❑ RESIGNATION (Q) <br />❑ RETIRED (R) <br />❑ LAID OFF (L) <br />❑ FAIL PROBATION (P) <br />❑ OTHER (0) <br />❑ PERFORMANCE (P) <br />❑ ATTENDANCE (A) <br />❑ CONDUCT (C) <br />❑ OTHER EMPLOYMENT (E) <br />❑ PERSONAL (L) <br />❑ OTHER (0) <br />❑ Eligible For Rehire ❑ Ineligible For Rehire <br />1 <br />Provide Details of Separation Below <br />COMMENTS: Increase per wage survey -payment effective 1/1/17; deferred until February payroll. <br />SECTION 3: POSITION DATA <br />Enter existing data from CAMAS Wage Data Report <br />Enter new data <br />JOB TITLE <br />PUBLIC HEALTH NURSE II <br />OCCUPATION CODE <br />2471 <br />UNION CODE <br />40 <br />PAY GRADE <br />271 <br />STEP / POSITION <br />6 <br />FLSA STATUS <br />it Non -Exempt ❑ Exempt ❑ Not Covered <br />El Non -Exempt ❑ Exempt ❑ Not Covered <br />DRS STATUS <br />❑ Ineligible ❑' PERS ❑ LEOFF ❑ PSERS ❑ Other <br />❑ Ineligible ❑' PERS ❑ LEOFF ❑ PSERS ❑ Other <br />HIRE DATE <br />6/22/2015 <br />ADJ HIRE DATE <br />7/13/2015 <br />POSITION DATE <br />6/22/2015 <br />LAST RAISE DATE <br />1/1/2016 <br />4 } <br />BASE WAGE <br />$4,151.00 <br />$ 4,381.00 <br />LONGEVITY <br />$ 0.00 <br />$ <br />FTE <br />❑� 100% [:180% ❑ 75% ❑ 60%E150% <br />❑� 100% ❑ 80% ❑ 75% ❑ 60% ❑ 50% <br />FTE WAGE <br />$ 4,151.00 <br />$ 4,381.00 <br />PAYMENT METHOD <br />❑ HOURLY ❑� MONTHLY <br />❑ HOURLY (j] MONTHLY <br />DEPARTMENT <br />PUBLIC HEALTH <br />BUDGET NUMBER <br />A. 116 000000000061251001 %: 100.00 <br />B. %: <br />A. %: <br />B. %: <br />WORKWEEK <br />❑� Standard ❑ ALT/1" Friday off: ❑ 207(k) <br />El Standard ❑ ALT/1" Friday off: ❑ 207(k) <br />To continue any allowance, stipend, or other, it must be listed in both columns for audit purposes or the amount will default to "0". <br />ALLOWANCE (Detail in Comments Section) $ 0,00 $ 0,00 <br />STIPEND (Detail in Comments Section) <br />$ 0.00 $ 0,00 <br />OTHER (Detail in Comments Section) <br />$ 0.00 $ 0.00 <br />SECTION 4: SIGNATURES (MUST BE SIGNED IN BLUE INK) <br />DE > ►� _.N Q/ ELECTS Ff1CIAL DATE <br />BUDGETIPAYROCL (lf-��7DATE <br />HU AN RESOURCE <br />CO IS5 # <br />DATECOMMf551 <br />�� <br />aATE <br />ql DAT <br />COMMS <br />RETURN FORM TOM)MAN RESOURCES FOR DISTRIBUTION <br />Updated: 04/08/11 FOR HR USE: NT Update Eval Date EvalRating(IE—ID—S—AA—S) Initial <br />