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Manhattan, KS 66506-4801

 

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Change or Separation Form (PER-39)

Fill out the Change or Separation Form (PER-39) (pdf)

The Change or Separation Form (PER-39) is used to process the following types of actions:

  • Name Change
  • Preferred Name
  • Address Change
  • Citizenship Status Change
  • Military Status Change
  • Visa Type Change
  • Marital Status Change
  • Pay Rate Change
  • FTE Change
  • Leave of Absence
  • Return from Leave
  • Reappointment
  • Appointment Basis Change
  • Sabbatical Leave
  • Phased Retirement
  • Separations

The information at the top of the form is designated as "Required" and must be completed for the change or separation. This information represents the current information of the employee prior to the new action.

Completing the Form for:

Unclassified Staff
Type of Employee
Required field. Choose Unclassified.
Employee Name
Enter the full name of the employee. Format should be mixed case, [First Name] space [Middle Name or Initial] space [Last Name] space [Suffix - if applicable].
Department ID
Identify the 10-digit department to which the position belongs. The first five digits are KSU Agency number "36700". The last five digits are the FIS department number. Example: President's Office — 3670001010.
Department Name
The department name (description) coinciding with the Department ID to which the position belongs.
Employee ID
An eleven-digit identification number assigned to the employee at the time of original hire.
RCD # (Employment Record #)
The employee's employment record number for which the change is being requested. For example, if you are updating Employment Record Number "0", indicate "0"; if updating Employment Record Number "1", indicate"1".
Effective Date
The date the action takes effect. All actions must have an "Effective Date." The effective date of a termination is the day following the last day of employment.
Position No.
The 8-digit position number that an employee is assigned to.
9- Month or 12-Month
Place an "X" in the appropriate box to indicate if the employee is 9 or 12 month.
Job Code
The 6-digit code associated with the job title of the position number.
Job Title
Job title description for the job code.
Change

Place an "X" in the box by the appropriate action. Indicate the new or correct information where applicable. Multiple actions may be indicated if the effective date of the action is the same. If there is other information not specifically indicated on the Change or Separation Form (PER-39), you may indicate the change under "Other".

Name Change
Place an "X" in the action box and indicate the new or correct name. Use the standard name format used in HRIS. Mixed case, [First Name] space [Middle Name or Initial] space [Last Name] space [Suffix - If Applicable]. Note: A copy of the social security card with the new name must be attached.
Address Change
Departments have access to update addresses in HRIS during the second week of each pay period. Instructions are available under Address and Phone Number on Managing Employee Information
Or list street/box number, city, state, county, country and home phone. The county identifies the two digit county code of the city of the Home Address. Refer to the list of codes for county abbreviations on the County Code Table (xls). Please note that this information will only be used for the faculty/staff portion of the KSU Campus Phone Book and will not be released by HR for any other purpose. Employees are able to withhold home phone and home address from the KSU Campus Phone Book by accessing Employee Self Service/Personal Information/Home Address in HRIS and selecting on the "Please do not print address and phone number in Campus Phone Book" checkbox.
Preferred Name
The preferred name is the name to be used in place of the name listed on the social security card and listed in HRIS. This is the name that will display on the white pages and campus phonebook. Example: First Name is William, Preferred Name is Bill.
Personal Change
Place an "X" in the box if any personal data is changing. Indicate the new information in the box provided.
    • Citizenship Status Identify the employee's citizenship. Place an "X" in the action box and indicate the new or correct information. If changing status from Alien Temporary to Alien Permanent, please attach appropriate documents, such as a permanent resident card, if applicable. Valid selections are listed below:
      • Alien Perm
      • Native
      • Alien Temp
      • Naturalized
    • Visa Type Place an "X" in the action box and indicate the new or correct information. An On-Campus work permit from International Student and Scholar Services for all employees. A change in Visa Type requires a new Form I-9 in order to re-verify employment eligibility. Valid Visa types are listed below.
      VisaType
      F1Student
      J1Exchange Visitor/Research
      J2Spouse/Child Exchange
      H1BTemporary Worker
      TNNafta Agreement (i.e. Canada or Mexico)
      O1Extraordinary Ability
    • Military Status Identify the military status of the employee. Place an "X" in the action box and indicate new or correct information. Refer to definitions, Military Status and Disabled Veteran's Definition.
      • Not Indicated
      • Other Vet
      • Active Reserve
      • Retired
      • Inactive Reserve
      • Vietnam Vet
      • No Mil Svc
    • Marital Status
    • Place an "X" in the box if any personal data is changing. Indicate the new information in the box provided. The following is a list of Marital Status options.
Marital Status
Common LawMarried
DivorcedSingle
SeparatedWidowed
Head of Household
Pay Rate Change (Biweekly)
List the new biweekly pay rate. If the employee has a contract, include a copy of the contract when submitting to Human Resources.
Pay Rate Change (Hourly)
List the new hourly pay rate. If the employee has a contract, include a copy of the contract when submitting to Human Resources.
FTE Change
Place an "X" in this action box if you are changing the tenths time (FTE) of an employee's position. Indicate the current FTE in the "From" block and the new FTE in the "To" block. Show as 1.0, .50, .30 etc. Indicate the new Benefit Program in the line provided, if there is a changes (i.e., full-time employee changes to PT1 for part-time). If the employee has a contract, include a copy of the contract when submitting to Human Resources. The Benefit Program is an indicator that determines Benefit Program eligibility and is based on full-time or part-time status and annual salary. Employees on temporary unclassified positions (less than 90 days or less than .5 FTE for any amount of time) do not receive benefits.
State of Kansas OptionsLocal Agency Options
GEN - No Benefits (General)GEN - No Benefits (General)
FT1 - Full-time (earnings less than $28,000 per year)ATH - Intercollegiate Athletics
FT2 - Full-time (earnings between $28,000 and $48,000 per year)PUB - Student Publications
FT3 - Full-time (earnings more than $48,000 per year)UN1 - K-State Student Union
PT1 - Part-time between .5 and .8 FTE
Leave of Absence
Place an "X" in this action box if an employee is going on leave of absence for more than 30 days. List the reason for the leave on the line provided. Include the request for approval for the leave of absence when submitting the form to Human Resources.
Return From Leave
Place an "X" in this action box if you are returning an employee to the payroll that has been on voluntary or involuntary leave of absence for more than 30 days.
Reappointment
Place an "X" in this box if you are reappointing a temporary unclassified employee and there is no break in service. Include an Appointment End Date. This date is used for temporary appointments that have an end of appointment date. List the employees expected last day of employment.
Appointment Basis Change
Place an "X" in this box for an employee who is changing Appointment Basis. Select on the appropriate checkbox to indicate if the employee is changing from 12-month to 9-month or 9-month to 12-month. Include the Compensation Rate in the appropriate field. Include a copy of the contract when submitting to Human Resources.
Sabbatical Leave
Mark the appropriate line for Half or Full Year sabbatical. List the employee's compensation rate. Include a copy of the sabbatical leave agreement when submitting to Human Resources.
Phased Retirement
List the reduced FTE for the phased retirement. List the phased retirement compensation rate. Include a copy of the phased retirement agreement and the contract when submitting to Human Resources.
Other
Use this action box for other types of action not listed on the form. An example of this might be a social security number correction.
Separation

This section of the form is used to indicate a separation from the University. To process a separation, complete the top section of form (required fields) and place an "X" under the appropriate "separation" action. NOTE: The effective date of a resignation is the day following the last day of employment. An Exit Interview (PER-16) or letter of resignation must also be submitted. Refer to PPM Chapter 4950, Clearance Procedures at Separation for additional information.

This form should not be submitted if an employee is changing to a different department with no break in service and if the employees benefit status is not affected. (Example: Employee is promoting from a benefit eligible position in Housing to a benefit eligible position in Facilities.) The transfer paperwork completed by the hiring department will separate the employee from their previous position. The PER-39 would be submitted if someone changed from a benefit eligible position to a non-benefit eligible position. It would also be submitted if an employee is transferring to another state agency.  

University Support Staff
Type of Employee
Required field. Choose University Support Staff.
Employee Name
Enter the full name of the employee. Format should be mixed case, [First Name] space [Middle Name or Initial] space [Last Name] space [Suffix - if applicable].
Department ID
Identify the 10-digit department to which the position belongs. The first five digits are KSU Agency number "36700". The last five digits are the FIS department number. Example: President's Office — 3670001010.
Department Name
The department name (description) coinciding with the Department ID to which the position belongs.
Employee ID
An eleven-digit identification number assigned to the employee at the time of original hire.
RCD # (Employment Record #)
The employee's employment record number for which the change is being requested. For example, if you are updating Employment Record Number "0", indicate "0"; if updating Employment Record Number "1", indicate"1".
Effective Date
The date the action takes effect. All actions must have an "Effective Date." The effective date of a termination is the day following the last day of employment.
Position No.
The 8-digit position number that an employee is assigned to.
9- Month or 12-Month
Place an "X" in the appropriate box to indicate if the employee is 9 or 12 month.
Job Code
The 6-digit code associated with the job title of the position number.
Job Title
Job title description for the job code.
Change

Place an "X" in the box by the appropriate action. Indicate the new or correct information where applicable. Multiple actions may be indicated if the effective date of the action is the same. If there is other information not specifically indicated on the Change or Separation Form (PER-39), you may indicate the change under "Other".

Name Change
Place an "X" in the action box and indicate the new or correct name. Use the standard name format used in HRIS. Mixed case, [First Name] space [Middle Name or Initial] space [Last Name] space [Suffix - If Applicable]. Note: A copy of the social security card with the new name must be attached.
Address Change
Departments have access to update addresses in HRIS during the second week of each pay period. Instructions are available under Address and Phone Number on Managing Employee Information
Or list street/box number, city, state, county, country and home phone. The county identifies the two digit county code of the city of the Home Address. Refer to the list of codes for county abbreviations on the County Code Table (xls). Please note that this information will only be used for the faculty/staff portion of the KSU Campus Phone Book and will not be released by HR for any other purpose. Employees are able to withhold home phone and home address from the KSU Campus Phone Book by accessing Employee Self Service/Personal Information/Home Address in HRIS and selecting on the "Please do not print address and phone number in Campus Phone Book" checkbox.
Preferred Name
The preferred name is the name to be used in place of the name listed on the social security card and listed in HRIS. This is the name that will display on the white pages and campus phonebook. Example: First Name is William, Preferred Name is Bill.
Personal Change
Place an "X" in the box if any personal data is changing. Indicate the new information in the box provided.
  • Citizenship Status Identify the employee's citizenship. Place an "X" in the action box and indicate the new or correct information. If changing status from Alien Temporary to Alien Permanent, please attach appropriate documents, such as a permanent resident card, if applicable. Valid selections are listed below:
    • Alien Perm
    • Native
    • Alien Temp
    • Naturalized
  • Visa Type Place an "X" in the action box and indicate the new or correct information. An On-Campus work permit from International Student and Scholar Services for all employees. A change in Visa Type requires a new Form I-9 in order to re-verify employment eligibility. Valid Visa types are listed below.
    VisaType
    F1Student
    J1Exchange Visitor/Research
    J2Spouse/Child Exchange
    H1BTemporary Worker
    TNNafta Agreement (i.e. Canada or Mexico)
    O1Extraordinary Ability
  • Military Status Identify the military status of the employee. Place an "X" in the action box and indicate new or correct information. Refer to definitions, Military Status and Disabled Veteran's Definition.
    • Not Indicated
    • Other Vet
    • Active Reserve
    • Retired
    • Inactive Reserve
    • Vietnam Vet
    • No Mil Svc
  • Marital Status Place an "X" in the box if any personal data is changing. Indicate the new information in the box provided. The following is a list of Marital Status options.
    Marital Status
    Common LawMarried
    DivorcedSingle
    SeparatedWidowed
    Head of Household
Pay Rate Change (Biweekly)
These fields are not used for university support staff and should be left blank.
Pay Rate Change (Hourly)
These fields are not used for university support staff and should be left blank.
FTE Change
Place an "X" in this action box if you are changing the tenths time (FTE) of an employee's position. Indicate the current FTE in the "From" block and the new FTE in the "To" block. Show as 1.0, .50, .30 etc. Indicate the new Benefit Program in the line provided, if there is a changes (i.e., full-time employee changes to PT1 for part-time). The Benefit Program is an indicator that determines Benefit Program eligibility and is based on full-time or part-time status and annual salary. Employees on temporary classified positions do not receive benefits. Employees on "regular" classified positions must have at least 1000 hours of compensable service to be eligible for a Benefit Program.
State of Kansas OptionsLocal Agency Options
GEN - No Benefits (General)GEN - No Benefits (General)
FT1 - Full-time (earnings less than $28,000 per year)ATH - Intercollegiate Athletics
FT2 - Full-time (earnings between $28,000 and $48,000 per year)PUB - Student Publications
FT3 - Full-time (earnings more than $48,000 per year)UN1 - K-State Student Union
PT1 - Part-time between .5 and .8 FTE
Leave of Absence
Place an "X" in this action box if an employee is going on leave of absence for more than 30 days. List the reason for the leave on the line provided. Include the request for approval for the leave of absence when submitting the form to Human Resources.
Return From Leave
Place an "X" in this action box if you are returning an employee to the payroll that has been on voluntary or involuntary leave of absence for more than 30 days.
Reappointment
Place an "X" in this box if you are reappointing a temporary classified employee and there is no break in service. Include an Appointment End Date. This date is used for temporary appointments or limited term appointments that have an end of appointment date. List the temporary employees expected last day of employment.
Appointment Basis Change
Place an "X" in this box for an employee who is changing Appointment Basis. Select on the appropriate checkbox to indicate if the employee is changing from 12-month to 9-month or 9-month to 12-month. Include the Compensation Rate in the appropriate field.
Sabbatical Leave
Not used for classified.
Phased Retirement
Not used for classified.
Other
Use this action box for other types of action not listed on the form. An example of this might be a social security number correction.
Separation

This section of the form is used to indicate a separation from the University. To process a separation, complete the top section of form (required fields) and place an "X" under the appropriate "separation" action. NOTE: The effective date of a resignation is the day following the last day of employment. An Exit Interview (PER-16) or letter of resignation must also be submitted. Refer to PPM Chapter 4950, Clearance Procedures at Separation for additional information.

This form should not be submitted if an employee is changing to a different department with no break in service and if the employees benefit status is not affected. (Example: Employee is promoting from a benefit eligible position in Housing to a benefit eligible position in Facilities.) The transfer paperwork completed by the hiring department will separate the employee from their previous position. The PER-39 would be submitted if someone changed from a benefit eligible position to a non-benefit eligible position. It would also be submitted if an employee is transferring to another state agency.

Graduate Student Employees
Type of Employee
Required field. Choose Graduate Student.
Employee Name
Enter the full name of the employee. Format should be mixed case, [First Name] space [Middle Name or Initial] space [Last Name] space [Suffix - if applicable].
Department ID
Identify the 10-digit department to which the position belongs. The first five digits are KSU Agency number "36700". The last five digits are the FIS department number. Example: President's Office — 3670001010.
Department Name
The department name (description) coinciding with the Department ID to which the position belongs.
Employee ID
An eleven-digit identification number assigned to the employee at the time of original hire.
RCD # (Employment Record #)
The employee's employment record number for which the change is being requested. For example, if you are updating Employment Record Number "0", indicate "0"; if updating Employment Record Number "1", indicate"1".
Effective Date
The date the action takes effect. All actions must have an "Effective Date." The effective date of a termination is the day following the last day of employment.
Position No.
The 8-digit position number that an employee is assigned to.
9- Month or 12-Month
Place an "X" in the appropriate box to indicate if the employee is 9 or 12 month.
Job Code
The 6-digit graduate student job code associated with the graduate student job title of the position number. (031000=Graduate Assistant; 032000=Graduate Research Assistant; 030500=Graduate Teaching Assistant)
Job Title
Job title description for the job code.
Change

Place an "X" in the box by the appropriate action. Indicate the new or correct information where applicable. Multiple actions may be indicated if the effective date of the action is the same. If there is other information not specifically indicated on the Change or Separation Form (PER-39), you may indicate the change under "Other".

Name Change
Place an "X" in the action box and indicate the new or correct name. Use the standard name format used in HRIS. Mixed case, [First Name] space [Middle Name or Initial] space [Last Name] space [Suffix - If Applicable]. Note: A copy of the social security card with the new name must be attached.
Address Change
Departments have access to update addresses in HRIS during the second week of each pay period. Instructions are available under Address and Phone Number on Managing Employee Information
Or list street/box number, city, state, county, country and home phone. The county identifies the two digit county code of the city of the Home Address. Refer to the list of codes for county abbreviations on the County Code Table (xls).
Preferred Name
The preferred name is the name to be used in place of the name listed on the social security card and listed in HRIS. This is the name that will display on the white pages and campus phonebook. Example: First Name is William, Preferred Name is Bill.
Personal Change
Place an "X" in the box if any personal data is changing. Indicate the new information in the box provided.
    • Citizenship Status Identify the employee's citizenship. Place an "X" in the action box and indicate the new or correct information. If changing status from Alien Temporary to Alien Permanent, please attach appropriate documents, such as a permanent resident card, if applicable. Valid selections are listed below:
      • Alien Perm
      • Native
      • Alien Temp
      • Naturalized
    • Visa Type Place an "X" in the action box and indicate the new or correct information. An On-Campus work permit from International Student and Scholar Services for all employees. A change in Visa Type requires a new Form I-9 in order to re-verify employment eligibility. Valid Visa types are listed below.
      VisaType
      F1Student
      J1Exchange Visitor/Research
      J2Spouse/Child Exchange
      H1BTemporary Worker
      TNNafta Agreement (i.e. Canada or Mexico)
      O1Extraordinary Ability
    • Military Status Identify the military status of the employee. Place an "X" in the action box and indicate new or correct information. Refer to definitions, Military Status and Disabled Veteran's Definition.
      • Not Indicated
      • Other Vet
      • Active Reserve
      • Retired
      • Inactive Reserve
      • Vietnam Vet
      • No Mil Svc
    • Marital Status
    • Place an "X" in the box if any personal data is changing. Indicate the new information in the box provided. The following is a list of Marital Status options.
Marital Status
Common LawMarried
DivorcedSingle
SeparatedWidowed
Head of Household
Pay Rate Change (Biweekly)
List the new biweekly pay rate.
Pay Rate Change (Hourly)
List the new hourly pay rate.
FTE Change
Place an "X" in this action box if you are changing the tenths time (FTE) of an employee's position. Indicate the current FTE in the "From" block and the new FTE in the "To" block. Show as 1.0, .50, .30 etc. The Benefit Program is GEN for graduate student employees.

 

Leave of Absence
Not used for Graduate Students.
Return From Leave
Not used for Graduate Students.
Reappointment
Place an "X" in this box if you are reappointing a graduate student employee and there is no break in service. Include an Appointment End Date. List the employees expected last day of employment.
Appointment Basis Change
Place an "X" in this box for an employee who is changing Appointment Basis. Select on the appropriate checkbox to indicate if the employee is changing from 12-month to 9-month or 9-month to 12-month. Include the Compensation Rate in the appropriate field.
Sabbatical Leave
Not used for Graduate Students.
Phased Retirement
Not used for Graduate Students.
Other
Use this action box for other types of action not listed on the form. An example of this might be a social security number correction.
Separation

The Separation section of the form is used to separate the employee from the university. To process a separation, complete the top section of the form (required) and place an "X" under the appropriate "Separation" action. For graduate students, select on "End of Temporary Appointment (ETM)". NOTE: The effective date of a separation is the day following the last day of employment. (Example: The employees last day is June 1st. The effective date would be June 2nd.)