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Employee Status Report
Please complete and return to Sara Fuentes.
Location: ☐State Headquarters ☐Orphan’s Heart ☐Lakeland ☐Miami ☐Jacksonville
☐ Tallahassee ☐Ft. Myers ☐Pensacola ☐Other _______________________
☐New Hire Date of hire: __________________________
☐Rehire Date of rehire: _________________________
☐Termination Date of termination: ____________________________
Reason for termination: ___________________________________________
☐Change Date of change: ____________________ Fill out name and items changed only.
Full Legal Name: ______________________ Preferred Name (if different): ___________________
Home Address: _______________________ Date of Birth: ______________________
City, State, Zip: _______________________ Gender: ☐Male ☐Female
Home Phone: ________________________ Social Security Number: ______________________
Spouse’s Name: ______________________
Pay Type: ☐Salaried Annual Rate: ______________________
☐Hourly Hourly Rate: _______________________
Work Type: ☐8842 (works with children) ☐8810 (does not work with children)
☐Full Time ☐Part Time Hours per pay period: __________ ☐On Call
Benefits: ☐Yes ☐No
PTOs: ☐25 ☐28 ☐30 ☐35
Ordained Minister: ☐Yes ☐No
Job Title: __________________________ Department number: _____________
Personnel History
Years Experience at Hire: ________________ Education Level at Hire: ________________
Salary Determination: Base______________________
Education__________ Experience ________ Location: __________ Additional Resp: _________
Totally Salary: _____________________
Comments: ________________________________________________________________________
__________________________________________________________________________________
Supervisor Approval: _________________________ Date: _______________________