Exit Interview Form Notification Of Termination printable pdf download

Exit Interview Form Notification Of Termination

Exit Interview Form/Notification of Termination

Name of Employee: ________________________

Date of exit interview: ______________________

Employee Supervisor: ______________________

Please be advised that (Name) _____________________________, Employee # _________, has

terminated employment with the Town of Berlin for the following reasons(s);

___ Quit, reason unknown

___ Quit, starting employment elsewhere

___ Discharged for Misconduct

___ Failed to meet performance standards

___ Lack of Work

___ Employee is retiring

___ Other: _________________________________________

Do you expect to recall this employee? ___ Yes ___ No

___ Employee is no longer considered an employee of the Town of Berlin for any reason (not

eligible to return at all).

___ Employee is no longer a permanent employee but may return from time to time as part-time

employee in my department.

___ Employee is no longer employed in our department, but remains working as a town

employee in the following capacity:

___ On-Call Patrolman or Dispatcher

___ Law Enforcement – Details/Special Duty

___ Election Worker

___ Highway – On-call snow plowing/tree removal/storm damage

___ Call Firefighter

___ EMT/First Responder

___ Substitute Teacher

___ Other: __________________________

Effective Date of Termination/Retirement: ___/___/____

Has employee been advised of COBRA rights if applicable? ___ Yes ___No ___N/A

Items to be returned (where applicable): employee to date and initial:

___ Keys

___ Computer Equipment

___ Blackberrry

___ Town Phone

Other items: __________________________________________

Signature of Former Town Employee: ________________________ Date:_____________

Signature of Supervisor: ___________________________________ Date:______________

Copy provided to Personnel Committee (date): __________

Copy provided to Town Treasurer (date): __________

Exit Interview Form Notification Of Termination