Department of Human Resources - Agency Resource Center

Shift Differential Request

*Funding: By indicating a yes or no in the box located on the last page, in addition to required signatures by the Appointing
Authority and, when applicble, the Chief Budget Officer, you are certifying you have the available funds to support this
request.

All fields are required. If the requesting agency has omitted pertinent information for DOHR to make the appropriate determination, then
this form may be returned to the requesting agency for additional information to be submitted before a final determination is made.

Agency Division / Program Area

Effective Date
Position Number
(Must be a Sunday)

Current Class Title Base Salary

(Salary at time S.D. began)

Employee Name Proposed Salary

Employee ID Percent Increase Requested

Employee Status Amount Difference

(flat dollar amount)

** Please note - if you are requesting more than one position or employee to receive a shift differential, you will need to
submit a spreadsheet with the following information: Employee Name, Employee ID, Position Number, Effective Date,
Classification Title, Base Salary, Proposed Salary & Shift Differential percentage amount.

If your agency has approval for a shift differential for positions performing on this shift, please attach original approval
memo to verify the differential is currently in place.

If this is to establish a shift differential, please explain the circumstances of why your agency is requesting a shift
differential.

If this is to establish a shift differential, please list below the shift(s) and the percentage of increase(s) each shift will
receive.

** Awareness Letter - Please have incumbent sign an awareness letter that they agree that the differential will be removed if
they are no longer working any of these shifts. You will not be required to submit the awareness letter to Agency Resource
Center (ARC). You will, however, need to retain the signed awareness letter in your HR Division.

Page 1 of 3
PR-0476 (Rev. 5/2016)
Department of Human Resources - Agency Resource Center
Shift Differential Request

* Funding: I, the Appointing Authority, or, when applicable, the Chief Budget
Officer, certify that there are available equity funds to support this request. (in the
box to the right, indicate a Yes or No)

Required Signatures

__________________________________________ __________________________________________
Agency Chief Budget Officer Agency Appointing Authority
(sign and date) (sign and date)

__________________________________________ __________________________________________
Agency Human Resources Officer (Director) Commissioner, Department of Human Resources
(sign and date) (sign and date)

Page 2 of 3
PR-0476 (Rev. 5/2016)
ABC
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