Change of Payroll Form

Change of Payroll Form

Required for changes to employee position, salary, department, or status.
Today's Date*

MonthDayYear
Date
Employee's Full Legal Name*

First NameLast Name
Change of Payroll Effective Date*

MonthDayYear
(Must be at the start of a Pay Period or beginning of the month for Pay Per Attended)
2025 Payroll Calendar
Change Request Reason*
Does the employee have direct reports?*

YesNo
Rate/ Salary Change Reason*
Other:*
Will the employee have new direct reports?*

YesNo
Please include the full first & last names of the direct reports and who they will be reporting to now.*
If the employee's direct reports are not changing, please type "no change."
If eligible, is the employee requesting an advance?

YesNo
If yes, amount requested:
(Note up to $2500 for associates, $3000 for independents)
Please list the department(s) the employee will be working in, their schedule for each, and any notes about their pay:*
Current Job Title*
Will the employee's job title change?

YesNo
New Job Title*
Current Department*
Will the employee's department change?*

YesNo
New Department*
Please indicate which departments and percentages.*
Work Location*

NO CHANGE in LocationIn-State RemoteAdmin OfficeOut-of-State RemoteEstrella ClinicHybridGilbert ClinicTempe Clinic
Please explain: *
Note: If primary supervisor is changing please be sure to fill out the new supervisor's contact information.
Will the employee's Supervisor change?*

YesNo
Current Supervisor's Legal Name*

First NameLast Name
New Supervisor's Legal Name*

First NameLast Name
New Supervisor's CPR Email Address*
example@cprecovery.com
Will the employee's Supervisor be the same as their Time Off Supervisor?*

YesNo
Will the employee's Time and Attendance Supervisor change?*

YesNo
New Time Off Supervisor's Legal Name*

First NameLast Name
Will the employee's current scheduled hours per week change?*

YesNo
Current Scheduled Hours Per Week *
New Scheduled Hours Per Week*
Employee's Weekly Schedule*
Days of the week/ times ex. Monday - Friday, 8 am - 5 pm with 1-hour lunch
Will there be any changes that impact the employee's pay (ie. Rate change, draw, pay dates, etc)?*

YesNo
Current Pay Rate*
Annualized if Salaried & Hourly if Bi-weekly
New Pay Rate*
Annualized if Salaried & Hourly if Bi-weekly
Pay Frequency*

Bi-Weekly (Hourly Employees)Semi-Monthly (Salaried Employees)Semi-Monthly (Pay Per Attended Employees)Semi-Monthly (Salary PLUS)
Pay Class*

Full Time Benefit Eligible (35+ Hours per week)Part Time Benefit Eligible (30-34 Hours or more per week)Part Time Limited Benefit Eligible (29 or less hours per week)
Clinician's License*

AssociateIndependent
Independent Draw Rate*
Updated monthly draw if applicable
Associate Draw Rate*
Updated monthly draw if applicable
Salary Plus Breakdown of Pay*
Other*
Comments
Is the employee a clinician?*

YesNo
Current Behavioral Health License*
Is the employee's behavioral health license changing?*

YesNo
New Behavioral Health License*
Notes:
Supporting Documentation

Cancelof
Requesting Manager's Full Legal Name*

First NameLast Name
Requesting Manager's CPR Email Address*
example@cprecovery.com
Executive's Name*
Executive's CPR Email Address*
Email
example@example.com
Executive Status*

ApprovedDeniedRequest an update
Updates needed:
Reason for denial
Executive Signature

Clear
I have made the requested changes

Confirmed
Should be Empty: