UT Physicians HR Equity Review Request Form

Requester Information:

Date:

Name:

Title:

Phone:

Email:

Incumbent Information:

Employee Name:

Employee ID

Department ID Number:
*Ensure that Department ID listed is the one from which salary and benefits are paid

Clinic Name:

Clinic Address:

Incumbent Job Code (You can find a list of job codes here):

Please provide a detailed reason for the single incumbent equity request:

***NOTE: Equity review results can take a minimum of 3 to 4 weeks from request submission.