DHS-0852-ENG 7-24 (1.2.7)

minnesota merit system

Report of Personnel Action

Required field

COUNTY AGENCY

EMPLOYEE FIRST NAME

EMPLOYEE LAST NAME

CLASSIFICATION

SALARY AMOUNT

SALARY TYPE

Hourly

Monthly

Yearly

SELECT THE ACTION TYPE

Appointments

Employee Actions

Separation Actions

Appointments

SELECT THE POSITION TYPE

New Position

Replacement

POSITION NUMBER (if known)

NAME OF PERSON REPLACED

If the duties to be performed are not the same as those performed by the previous incumbent, please submit position description form DHS-0876.

SELECT THE TYPE OF APPOINTMENT

Submit position description form DHS-0876.

SELECT THE NUMBER OF DAYS

45 days

67 days

EXPIRATION DATE

SELECT THE DURATION

Six months

One year

END DATE

SELECT THE TYPE

Probationary

Permanent

PROBATIONARY END DATE

Employee Actions

SELECT THE EMPLOYEE ACTION TYPE

SELECT TYPE OF REALLOCATION

Probationary

Permanent appointment

SELECT TYPE OF SALARY CHANGE

Increase

Decrease

NEW SALARY AMOUNT

NEW SALARY TYPE

Hourly

Monthly

Yearly

Submit position description form DHS-0876.

ANTICIPATED END DATE OF PROBATIONARY PERIOD

Submit Probationary Evaluation form DHS-0857.

Also submit any pertinent correspondence.

KIND

UNTIL (date)

RETURN DATE

BEGIN (date)

END (date)

EXPLAIN SCHEDULE CHANGE

SUSPENSION BEGINS (date)

SUSPENSION ENDS (date)

EMPLOYEE FIRST NAME EDIT

EMPLOYEE LAST NAME EDIT

Both employee name fields must be filled in the Employee Information tab.

CLASSIFICATION EDIT

Submit Probationary Evaluation form DHS-0857.

Separation Actions

SELECT THE SEPARATION TYPE

Submit DHS-0858-ENG in addition to this form

Authorization

By checking this check box and typing my name in the "Electronic Signature" field, I understand that I am electronically signing this form. In addition, I attest and certify that the information provided above is true and accurate. I understand that my electronic signature has the same legal effect and can be enforced in the same way as a handwritten signature. (MN Stat. §325L.07)

EFFECTIVE DATE OF ACTION

SIGNATURE OF DIRECTOR OR DESIGNEE

Send a copy of this form to the submitter

Enter your email address below, and a confirmation including a PDF file of the information provided will be sent to you.

SUBMITTER EMAIL ADDRESS

Send a copy of this form to the Director

DIRECTOR EMAIL ADDRESS

DHS Use Only

The status of the employee after the effective date of this action is:

APPLICANT ID

POSITION NUMBER

CLASS CODE

POSITION NUMBER BEFORE

POSITION NUMBER AFTER

DHS ACTION

APPROVED BY

Form State Cd