Community Development Department Use ONLY:
Reviewed by: ______________________________ Date: ____________
Approved by: ______________________________ Date: ____________
10/2020
Staff Change Form
You must complete this form if there are any staffing changes related to your grant funded project/program; new hires, change in job
descriptions, etc. Failure to do so may result in suspension of your grant.
Grant Type: _______________________ IDIS No: ______ ORD. No: ______ - _____
Organization Name: __________________________________________________
Physical Address: ____________________________________________________
Contact Phone Number: ______________________________________________
The following personnel changes have taken place within the above referenced organization effective as of
the _____ day of ______________, ________.
New Hire Employee Removed Change in Job Description
Name of Personnel: ____________________________ Signature of Staff Member: __________________________
Title of Personnel: _____________________________ Contact Phone Number: _____________________________
Brief Description of Grant Responsibilities: __________________________________________________________
________________________________________________________________________________________________
New Hire Employee Removed Change in Job Description
Name of Personnel: ____________________________ Signature of Staff Member: __________________________
Title of Personnel: ____________________________ Contact Phone Number: _____________________________
Brief Description of Grant Responsibilities: ___________________________________________________________
_________________________________________________________________________________________________
New Hire Employee Removed Change in Job Description
Name of Personnel: ____________________________ Signature of Staff Member: __________________________
Title of Personnel: ____________________________ Contact Phone Number: _____________________________
Brief Description of Grant Responsibilities: ___________________________________________________________
_________________________________________________________________________________________________
I, _________________________ certify and approve the above referenced staff changes for our organization’s
federally funded program/project.
__________________________________________________________________________________________
Name and Title Signature Date
