Fillable Employee Separation Form printable pdf download

Employee Separation Form

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EMPLOYEE SEPARATION FORM

EMPLOYEE NAME AND NUMBER:

POSITION:

SUPERVISOR:

HIRE DATE:

EFFECTIVE DATE:

LAST DAY WORKED:

TYPE OF SEPARATION:

Voluntary Quit

Involuntary Quit

Other (Please Explain)

REASON FOR SEPARATION:

Lack of work

Voluntary

I-9 Non-Compliance

Violation of Company Policy (Conduct, Performance, etc.)

Please explain

EVALUATION: Check each box below for which the employee’s performance was acceptable.

Production

Conduct

Safe Practices

Quality

Attendance

Adherence to Policy

IS EMPLOYEE ELIGIBLE FOR REHIRE?

YES

FORWARD EMAILS AND PHONE TO__________________________________________________

______________________________________________________________________________

BELOW IS FOR OFFICE USE ONLY

Initial

Checklist

Deduct screening costs

I-9:

File in termed I-9 folder

COBRA:

Notify Cornerstone

BENEFITS:

Health

Dental

Vision

Life

401(k)

FSA

iPS:

Terminate in iPS

Calculate Vacation: Days in year – 365 (Ttl Vac – Vac Used) = Vacation days to be paid ______

Calculate Final Check $

Final Check:

Mail

Hold for pick up

Direct Deposit

NOTIFY PAYROLL DEPARTMENT

GARNISHMENTS

Notify iPS

State or County Official if relevant

M2M: Terminate in M2M

Disable ALL network access, remote access, email, phone

PERSONNEL FILE: Update file, insert benefit file inside and file in terminated drawer

OBTAIN COMPANY OWNED PROPERTY: Computer, Phone, ID Badge, Keys, Credit Cards, Building Keys, Hard Hat

Disable Alarm Password

Notify IT (Server Access, Emails, Passwords)

Notify Admin (Enterprise, etc.)

***PLEASE COMMENT ON EVENTS SURROUNDING TERMINATION***

(Attach copy of documented employee warnings if applicable)

Employee Signature

Date

Supervisor Signature

Date

Exchange/Document Management/2017 Documents & Forms

Revised 11/03/16

Employee Separation Form

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