Service Desk Entry Step 1 of 3 33% "*" indicates required fields Managerial Information Requestor Name First Last Work Email Phone NumberRegional VP Carlos Rivera Eric Wheeler Jaime Restrepo Edita Gargovic Elgar Quijandria Submission Date MM slash DD slash YYYY Request TypeDepartment* Human Resources Operations / IT Safety HR Category* New Hire Information Re-Hire Resignation/Retire Termination Change of Address Retro Pay Leave of Absence Pay Rate Change Transfer Employee of the Month Uniform Ordering Shoe Reimbursement Employee Relations Operations/ IT Category* Business Cards Email Signature Gift Card ID Badge Safety Category* Accident Reporting This field is hidden when viewing the formNew Hire SectionNew Hire Employee Information Employee Name* First Last Date of Birth* MM slash DD slash YYYY Home Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Job Location / Site*Job Number*Job Title / Role*Pay Rate*Hours Scheduled per Week**40hrs, 20hrs, etc.Shift* AM PM Overnight Position Type* New Hire Replacement Employee being Replaced*Last Day of Work for Employee being Replaced* MM slash DD slash YYYY Termination PA Submitted* Yes Not Yet Additional Notes This field is hidden when viewing the formRe-Hire SectionRe-Hire Employee Information Employee Name* First Last Last 4 SSN*Home Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* MM slash DD slash YYYY Telephone*Job Location / Site*Job Number*Job Title*Pay Rate*Scheduled Days to Work* Monday Tuesday Wednesday Thursday Friday Saturday Sunday Hours Scheduled per Week**40hrs, 20hrs, etc.Employment Type* Union Non-Union Position Type* Added Position Employee Replacement Replaced Employee*Last Day of Work for Employee being Replaced* MM slash DD slash YYYY Termination PA Submitted* Yes Not Yet Additional Notes This field is hidden when viewing the formResignation/Retire SectionResignation Employee Information Employee Name* First Last Employee ID #*Job Location / Site*Job Number*Future Eligibility* Eligible for Re-Hire Do Not Re-Hire Proof of Resignation/Retirement* Drop files here or Select files Max. file size: 50 MB. Additional Notes* This field is hidden when viewing the formTermination SectionTermination Employee Information Employee Name* First Last Employee ID #*Job Location / Site*Job Number*Future Eligibility* Eligible for Re-Hire Do Not Re-Hire Additional Notes* This field is hidden when viewing the formChange of Address SectionChange of Address Employee Information Employee Name* First Last Employee ID #*Job Location / Site*Job Number*W-4 Upload*Max. file size: 50 MB. Additional Notes* This field is hidden when viewing the formRetro Pay SectionRetro Pay Employee Information Employee Name* First Last Employee ID #*Job Location / Site*Job Number*Date & Hours*DateAmount of Hours Add Remove*if multiple days are being requested, please select the "+" sign for more entries. Additional Notes* This field is hidden when viewing the formLeave of Absence SectionLeave of Absence Employee Information Employee Name* First Last Employee ID #*Job Location / Site*Job Number*Leave from Date* MM slash DD slash YYYY Leave to Date* MM slash DD slash YYYY Additional Notes* This field is hidden when viewing the formPay Rate SectionPay Rate Change Employee Information Employee Name* First Last Employee ID #*Job Location / Site*Job Number*Previous Amount*New Amount*Additional Notes* This field is hidden when viewing the formTransfer SectionTransfer Employee Information Employee Name* First Last Employee ID #*From Job Number*To Job Number*Job Title*Pay Rate*Scheduled Days to Work* Monday Tuesday Wednesday Thursday Friday Saturday Sunday Hours Scheduled per Week**40hrs, 20hrs, etc.Employment Type* Union Non-Union Position Type Added Position Employee Replacement Other Replaced Employee*Additional Notes* This field is hidden when viewing the formEmployee Nomination SectionEOM Nomination Employee Information Year:*For the Month of:* Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Employee Name* First Last Employee ID #*Job Location / Site*Job Title* Please provide detailed, specific examples for each of the following categories:Quality of Work*(Maintains high cleaning standards)Reliability*(Strong attendance and punctuality)Customer Feedback*(Positive comments from clients or supervisors) Teamwork*(Supports colleagues and fosters a positive environment) Initiative*(Suggests improvements or goes beyond assigned duties) Additional Reasons for Nomination / General Comments This field is hidden when viewing the formUniform Request SectionUniform Request Employee Information *All employees will receive 5 Polos & 2 Vest Job Location / Site*Job Number*Enter Employees Below Order Request Type*New EmployeeRenewalEmployee Name* First Last Employee ID #*Employment Status*Select OneFull TimePart TimeShirt Type*Select OnePolo ShirtT-ShirtShirt Size*Select OneUnisex-SmallUnisex-MediumUnisex-LargeUnisex-(x)LargeUnisex-(xx)LargeUnisex-(xxx)LargeVest TypeSelect OneFleece VestVest Size*Select OneUnisex-SmallUnisex-MediumUnisex-LargeUnisex-(x)LargeUnisex-(xx)LargeUnisex-(xxx)LargeHat TypeSelect OneBaseball CapBeanieWInter Jacket SizeSelect OneUnisex-SmallUnisex-MediumUnisex-LargeUnisex-(x)LargeUnisex-(xx)LargeUnisex-(xxx)Large Additional NotesAdd any relative notes regarding uniforms for this location (ex. special logo required, specialized uniform pieces, etc..) This field is hidden when viewing the formShoe Reimbursement SectionShoe Reimbursement Employee Information Employee Name* First Last Employee ID #*Job Location / Site*Job Number*Date of Purchase* MM slash DD slash YYYY Purchase Total Amount*Proof of Purchase* Drop files here or Select files Max. file size: 50 MB. This field is hidden when viewing the formEmployee Relations SectionEmployee Relations Location where this happened Job Location / Site*Job Number*Union Associated with Employee* 32BJ, New York 32BJ, New England 32BJ, Connecticut 32BJ, New Jersey 32BJ, Philadelphia/Delaware 32BJ, Massachusetts (Local 615) SEIU, Local 6 SEIU, Local, Northern California SEIU, Local, Southern California SEIU, Local 1, Chicago RWDSU UFCW, Local 1102 USWU, Local 74 N/A Employee Name* First Last Describe what happened*Enter as many details as possible Upload any relevant photos or supporting documents here Drop files here or Select files Max. file size: 50 MB. This field is hidden when viewing the formBusiness Card SectionBusiness Cards Employee Information Employee Name* First Last Title*Email* Phone Number*Secondary Phone Number*Shipping Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code *If you are based in the NY/NJ area, please use the main office address This field is hidden when viewing the formEmail Signature SectionEmail Signature Employee Information Employee Name* First Last Title*Phone Number*Secondary Phone Number*Work Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code This field is hidden when viewing the formGift Card SectionGift Card Employee Information Enter Employees Below Employee Name* First Last Employee ID #*Reward Purpose* Operational Excellence Customer Compliment Client Appreciation Employee of the month Other Request Amount*Additional Reasons for Nomination This field is hidden when viewing the formID Badge SectionID Badge Employee Information Enter Employees Below Employee Name First Last Employee ID #Photo UploadMax. file size: 50 MB. Shipping Address New York HQ Chicago Walpole, MA Auburn, MA Texas Southern California Northern California Pacific Northwest * This field is hidden when viewing the formAccident Reporting SectionAccident Reporting Involved Employee's Information eHub Action Item Opened* Yes No Did Employee call WorkCare* Yes No Reasoning for No*Involved Employee* First Last Employee ID #*Primary Language*Job Number*Is a Union Member* Yes No Job Location / Site*Job Title*Employee Typical Job Duties* Accident Report Details Date of Accident* MM slash DD slash YYYY Time of Accident*Date Accident was Reported* MM slash DD slash YYYY Time Accident was Reported*How was the Supervisor Aware/Notified of Accident* Witnessed Accident In Person By Telephone Other Please Explain*Reported By* First Last Telephone Number* Injury Report Section Exact Location/Area where Accident Occured*Was the Accident Preventable? Explain HOW and WHY the Accident Occured*Nature of Injury (Strain, Cut, Bruise)*Body Parts Affected (Be Specific: left hand, or right ankle)*Was the Employee Following Safety Protocol and/or Wearing Proper PPE? Explain*Medical Treatment* None Required Refused First Aid/Medical Care (complete refusal) On-Site First Aid Urgent Care Emergency Room Hospital Physician Other Did Employee Leave Work Due to Injury* Yes No Time Left*Transportation* Walked Private Vehicle Ambulance Company Vehicle Unknown Has the Hazard been Corrected* Yes No If no, why not*What Corrective Actions Have Been Taken to Prevent Future Accidents? Explain*Accident as Described by the Involved Employee*Additional Comments and NotesAttach any Relevant Photos to this Accident Drop files here or Select files Max. file size: 50 MB. Workers' compensation fraud statement: Any person who knowingly and with intent to defraud presents, causes to be presented, or prepares with knowledge or belief that it will be presented to, or by an insurer, or self-insurer, any information containing any false material statement or conceals any material fact, shall be guilty of a crime and subject to substantial fines and imprisonment. My signature affirms that the information that I am providing is true and accurate to the best ofmy knowledge and belief. I understand that this information may be used to make a claim under the New York State Worker's Compensation Law. I am fully aware that filing a false or misleading Workers' Compensation claim is a crime punishable by law. Acknowledgement Sign Off*I have reviewed and confirmed all the information I am submitting is accurate. Δ
