SR3-C
Temporary Change/Stipend Request
Department #:
Requesting Department:
Department Director/Chair:
PROPOSED CHANGE(S):
(Attach new Job Description or description of additional responsibilities)
Employee Name:
CURRENT
PROPOSED
Position Title:
From:
To:
Full Time/Part Time:
From:
To:
Permanent/Temporary:
From:
To:
Exempt/Non-exempt:
From:
To:
Work Year (Calendar/Academic):
From:
To:
Hours Per Week:
From:
To:
Weeks Per Year:
From:
To:
Monthly/Hourly Wage:
From: $
To: $
Base Annual Salary:
From: $
To: $
Adjusted Annual Salary:
From: $
To: $
Other Adjustments:
From: $
To: $
Stipend Amount:
Monthly:
Weekly:
GL#:
%:
GL#:
%:
Start:
End:
Funding Source(s):
Start/End Date:
Reason: Provide a description of the reason for the request; attach a separate page if necessary.
Endorsed:
Authorized
Division Head/Dean
Date
Provost (for academic positions)
Date
AVP for Human Resources
Date
President
Date
AVP & Controller, Financial Services
Date
VP for Finance and Administration
Date
Rev. 2/9/2016
Temporary Change/Stipend Request – Approval Process
This form is used to request a temporary stipend or temporary change to an existing position.
If you need assistance completing this form, please contact Human Resources
1. Complete the form, making sure all of the required information is included and send to your
Division Head/Dean for endorsement.
2. If the Division Head/Dean does not endorse your request, he/she will return the form to you.
3. If the Division Head/Dean endorses your request, he/she will notify you and send the signed
form to the AVP for Human Resources.
4. The AVP for Human Resources will review the request for parity and FLSA approval and, if
approved, forward to the Controller.
5. The Controller will certify that funding is available and, if so, will forward administrative
department staff requests to the VP, Finance and Administration, or, if the request is for
academic department staff, it will be forwarded to the Provost for his approval and then be
forwarded to the VP, Finance and Administration. If the request is not approved, it will be
returned to the Division Head/Dean.
6. Upon final approval, the VP, F/A will forward the approved form to the AVP for Human
Resources who will process the request.
Rev. 2/9/2016