Print

Skills >> Browse Articles >> Tools and Policies

Rate

Employee Separation Form

March 10, 2008

This Employee Separation form is used to document a terminating employee’s name and identification details, reason(s) for terminating, and effective date. It also documents the appointment details of a confidential Exit Interview scheduled with a representative of the Human Resources. It serves as a checklist for termination of other HR and payroll benefits and deductions.

Employee Separation

Date: __________________

Employee: ______________________________________ Employee ID Number: _____________________________ Department: ___________________________ Last Day Worked: _______________________ Job Title: _______________________________________________________________

Forwarding Address:




Each terminating employee is requested to complete a confidential Exit Interview with a representative of the Human Resources department. Please schedule this interview with your supervisor and note the date and time below.


Employee’s Signature

Exit Interview: Time: ____________________ Date: _____________________

Supervisor: ______________________________________________________________


To be completed by supervisor:

Separated:

Resignation

Discharge Other_____________________________

Reason for Separation: ___________________________________________________ ________________________________________________________________________

Termination Effective Date: _______________________ Last Day Worked: _______________________________

(If these two dates vary, please explain): ______________________________________________________________________

Notice Given:

Yes

NoDate_____________________________

Eligible for Rehire:

Yes

No

(If not, explain fully): ___________________________________________________________________________

HR Office Use Only:

PDO:

Paid

Unpaid

Number of additional hours to be paid ____

Explanation (if additional hours are to be paid): ________________________________________________________________________

Cancellations:

BC/BS

L.I. I.N.A.Termination Code: ||

PDO Accrual:   ||||||

Deduction Code:   ||       || ||

|| ||

Authorization:

Department Head ____________________________ Personnel __________________________________ Payroll ____________________________________


Poll: How do you feel about crying at work?

Poll: How do you feel about crying at work?