Headcount & Resignation Request Form

HEADCOUNT REQUEST FORM
Please utilize this form to request HC (headcount), either replacement or addition to staff. In addition will drive the following:
- standardized approach
- one platform to track HC requests and approvals
- trend 'replacements' vs. 'additions' by locations and positions
- actual vs. budget
Employee/Labor costs directly impact the bottom line - we need to ensure we are maximizing and driving productivity as best as we can through process improvements, scheduling efficiencies, etc.

Once position is approved, Regional Manager or HR will notify you of approval. Please proceed with posting job, etc. HR will track open requisitions on a spreadsheet for all open positions.
Office Location
Office Location
Manager requesting HC

First NameLast Name
Email
example@example.com
Position requesting
Please enter position, if not listed above
Position type (ex: full-time/part-time)
Is position budgeted?
Confidential Search
If we need to search to replace an individual that is not aware that we are going to replace them
Was position on hold due to COVID-19?*
REPLACEMENT INFORMATION
Headcount Request*

Replacement of StaffAddition to StaffNew PositionOther
If replacement, please enter name of employee resigning
If replacement, please enter hourly rate of person in role currently ($)
Is person leaving involuntary or voluntary?
Is this person a high performer? Someone the doctor really relies on?*
Why did employee cite leaving?*
Is this someone we want to retain?
If you'd like to retain please contact your HR Generalist and Regional Manager
If replacement, what is the date employee is leaving?
If replacement, why is person leaving?*
Please make sure you send employee exit survey link: https://www.surveymonkey.com/r/Riccobeneexitsurvey
Have we tried to retain this person, if person is someone we want to keep? (Please provide details if applicable). This will help HR/Recruiting team understand turnover.*
If we want to keep person, discuss with Regional Manager options.
What is the work schedule you are looking for this position (ex: 5 days, normal hours or 4/10's (7AM-6PM, M-Thursday)*
What is skill set of person leaving? (ex: implants, invisalign, etc.)*
If Dental Assistant, what certifications are needed:*

x-raynitrouscoronal polishingOther
If Dental Assistant, what procedures do you feel would be a need*

implantssurgeriesendohygieneOther
If Dental Assistant, is your Doctor willing to train?*
Have you talked to your doctor about willingness to train if we hire right attitude, etc.
What would you think would be a good culture fit?*
(ex: bubbly vs. quiet, etc.)
If replacement, please input employee's current pay rate
Hourly rate/salary range requested ($)
Metrics used to determine additional staff

Increase of doctor daysExpansion# of New patients increase# of patients seenOther
Please provide as much detail below per your metrics selection:

Please provide level of detail below regarding current staffing levels:

	Doctors (# of docs each day)	Dental Assistants	Dental Hygienists	Patient Coordinators	Sterilization Techs	Insurance Coordinators	Collections Coordinators
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
[other items to note]

What work will be in jeopardy if position is not filled? (Be Specific)
Why won't re-purposing existing headcount work?
NEW POSITION ONLY. Please elaborate in detail what this new position would be doing (ex: job duties, skills, responsibilities)?
NEW POSITION ONLY. Please elaborate what success looks like for this position? What metrics would you be using to measure success.
Please upload any additional information

Browse Files

Cancelof
Priority level so Andy can manage workload and allocate his time accordingly. If need to be, he may need to solicit OM/RM help pending workload.

High priority (needed immediately, impacting patients seen)Medium priority (there are current work arounds with current staffing to make it work until right candidate is located)Low priority (future need - adding a doctor, or confidential future planning, etc.)
Comments
Should be Empty:

HEADCOUNT REQUEST FORM

REPLACEMENT INFORMATION