DEPARTMENT OF ECONOMIC OPPORTUNITY

PERSONNEL ACTION

DEO FORM HRM-1 (Rev. 06/12)

A. PRESENT PERSONNEL STATUS	B. NEW EMPLOYEE OR CHANGE
1 SOCIAL SECURITY NUMBER	EMPLOYEE ID	SOCIAL SECURITY NUMBER	EMPLOYEE ID
2 NAME	NAME
3 HR ORGANIZATION NUMBER	FLAIR ORG NUMBER	HR ORGANIZATION NUMBER	FLAIR ORG NUMBER
4 OFFICE	COUNTY	OFFICE	COUNTY
5 FLAIR ACCOUNT CODE	FLAIR ACCOUNT CODE
6 BROADBAND CODE	BROADBAND OCCUPATIONAL TITLE	BROADBAND CODE	BROADBAND OCCUPATIONAL TITLE
7 CLASS CODE	CLASS TITLE	CLASS CODE	CLASS TITLE
8 POSITION NO.	SHARED EMP	PAYGRADE/PAYBAND	PAY PLAN	EMP. FTE	POSITION NO.	SHARED EMP	PAYGRADE/PAYBAND	PAY PLAN	EMP FTE
9 LAST TYPE OF ACTION	TYPE OF ACTION
10 EFFECTIVE DATE	STATUS	EFFECTIVE DATE	STATUS
11 STATUS EXP.	CONT SVC DATE	AG. HIRE DATE	ST. HIRE DATE	STATUS EXP.	CONT SVC DATE	AG. HIRE DATE	ST. HIRE DATE
12 LOA TYPE	LOA EFF. DATE	LOA RETURN	LOA TYPE	LOA EFF. DATE	LOA RETURN
13 PERFORMANCE EVAL	PERF. EFF. DATE	NEXT EVAL DUE	PERFORMANCE EVAL	PERF. EFF. DATE	NEXT EVAL DUE
14 BASE PAY RATE (m)	PAY RATE (m)	HR. BASE PAY	HR. PAY RATE	BASE PAY RATE (m)	PAY RATE (m)	HR. BASE PAY	HR. PAY RATE
15 CAD	LEADWORKER	SHIFT %	SHIFT AMT	ON CALL	CAD	LEADWORKER	SHIFT %	SHIFT AMT	ON CALL
16 BIRTHDATE	RETIREMENT	CITIZENSHIP	RACE	SEX	BIRTHDATE	RETIREMENT	CITIZENSHIP	RACE	SEX
17PUBLIC REC. EXEMPT	VET PREF	DUAL AGENCY	VOL TRANS/DEMOT.	PUBLIC REC. EXEMPT	VET PREF.	DUAL AGENCY	VOL. TRANS/DEMOT.
YES	NO
YES	NO	YES	NO
YES	NO
17 MARITAL STATUS	HOME PHONE	MARITAL STATUS	HOME PHONE
HOME MAILING ADDRESS	HOME MAILING ADDRESS
21 CITY	STATE	ZIP + 4	CITY	STATE	ZIP + 4
22 OFFICE PHONE (reg.)	ALTERNATE PHONE NUMBER	OFFICE PHONE (reg.)	ALTERNATE PHONE NUMBER
23 OFFICE EMAIL ADDRESS	SUPERVISOR POSITION NO	OFFICE EMAIL ADDRESS	SUPERVISOR POSITION NO
COMMENTS/JUSTIFICATION:

OFFICE ADDRESS:

24 REASON FOR SEPARATION	CODE	RECOMMEND REEMPLOYMENT
25 OFFICIAL SIGNATURE	DATE	BUDGET	DATE
26 OFFICIAL SIGNATURE	DATE	CONTRACTS AND GRANTS	DATE
27 DEPUTY SECRETARY/DIVISION DIRECTOR

SIGNATURE	DATE	HRM	DATE

PERSONNEL COPY

OPT-1 FORM

OSAS

2021-08-11

Barrett-Elmer, Judy

AWI