Employee Data Sheet - Part A | Kansas Department of Administration

Last Name:

First Name:

Email of Person Submitting Request:

*

Telephone Number of Person Submitting Request:

Action:

Add

Update

Correct

Delete

Please include any information below that will help process this request:

Empl. ID:

Dept. ID:

Dept. Name:

Empl. Rcd. Nbr.:

Position Nbr.:

Effective Date:

Name (Last, First, MI)::

Prefix:

Mr.

Mrs.

Miss

Ms.

Dr.

Birthdate:

Date of Death:

Effective Date:

Gender:

Female

Male

Unknown

Highest Education Level:

Marital Status:

Marital Status Date:

Address Type:

Address 1:

Address 2:

City:

State:

County:

Country:

Zip Code:

Ethnic Group:

Date Entitled to Medicare:

Military Status:

Citizenship - Proof 1:

Citizenship - Proof 2:

Eligible to work in US?:

Yes

No

Effective Date:

Effective Date Sequence:

Action Code:

Reason Code:

Position Number:

Job Code (Defaults from Position Data):

Tax Loc.:

FICA Status:

Holiday Schedule:

Grade/Step:

Compensation Rate:

Employment Status:

Probation

Permanent

Trainee

Not Applicable

Probation End Date:

Schedule Effective Date:

Schedule ID:

Benefit Record Number:

Program Effective Date:

Annual Benefits Base Rate:

Bas Group ID:

Eligibility Field 1:

Eligibility Field 2:

Benefit Program:

Add Years:

Subtract Years:

Add Months:

Subtract Months:

Add Days:

Subtract Days:

Payable Time Start Date:

Effective Date:

Time Reporter Status:

Active

Inactive

Time Reporter Type:

Elapsed

Time Elasped Template:

Workgroup:

Taskgroup:

TCD Group:

(Interface Agencies Only)

Consent Confirmation:

*

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Employee Data Sheet - Part A

SOCIAL SECURITY NUMBER - DO NOT submit the SS# through e-mail. Please contact your HR Consultant if the SS# is required for a data change.

Length of Service Adjustments

Please remember to fill out the EMPLID, DEPTID and Name at the top of this form