Employee Separation Report Form
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1Employee Separation Report
Employee Name:
ID #:
Home Address:
City:
State:
Zip:
Employer Name:
Position:
Department:
Division:
Supervisor:
SSN:
Hire Date:
Last Date Worked:
Date Term.:
Reason for Separation
Regular Employee:
Discharge
Layoff
Resignation
Other:
Temporary Employee:
End of term
Resignation
Discharge
Other:
Reason for Discharge:
Conduct
Attendance
Performance
Medical
Reason for Resignation:
Relocation
New job
Personal Reasons
Retirement
Medical
School
Dissatisfied with job
Family
Administrative Processes
Severance Package: $
Vacation Accrued:
hours
Benefits Conversion Explained to Employee
Final Pay Processed
Separation Filed
Equipment Returned:
Keys
Garage Pass
ID Badge
Other:
Insurance Companies Notified:
Health
Life
Dental
Other:
Employee Signature
Date Signed
Supervisor Signature
Date Signed
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