Employee Resignation Form
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1EMPLOYEE RESIGNATION
Employee Name:________________________________________ Social Security Number:_____________________
Street Address:____________________________________ Apt:________ City:_________________ State:_______ Zip Code:_________
Work Phone Number:__________________________________ Home Phone Number:___________________________________
School/Department Code/Name:_______________________________________ Position/Title_____________________________
Employment Start Date:_____________________________ Anticipated Last Date of Employment:_________________________
PLEASE CHECK ONE OF THE FOLLOWING
I am leaving the Halifax County School System due to: _______Employee Resignation _______ Employee Leave of Absence
Please circle the primary reason for your Resignation or Leave of Absence below:
Reason for Resignation
01 Another Position
09 Dismissal/Not Recommended
17 Deceased
02 Professional Improvement
10 Personal Reasons
18 Dismissal
03 Assignment Completed
11 Spouse Transferred
19 Insufficient Support from School Admin
04 Certification Problem
12 Abandon Position
20 Lack of Parental Involvement
05 Leaving the Teaching Profession
13 Illness
21 Poor School Climate
06 Financial Reasons
14 Marrying and Moving
22 Inadequate Support from HR
07 Military Career
15 Moving Out of the Area
23 Lack of Community Support
08 Retiring
16 Family Responsibilities
24 Other__________________________
_______________________________
_______________________________
Employee Signature:_________________________________________________________ Date:__________________________
Is there anything that could/should have been done that would have caused you to remain employed in your school or department?
Comments:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
____________________________________________________________________________________________
TO BE COMPLETED BY THE PRINCIPAL/DEPARTMENT HEAD
I have met with the employee and discussed the Resignation/Leave of Absence Request. The employee has ____agreed
____ not agreed to turn in all necessary materials (books, records, etc.) before leaving the school/department.
Principal/Department Head Signature:__________________________________________ Date:___________________________
TO BE COMPLETED BY REPRESENTATIVE IN THE DEPARTMENT OF HUMAN RESOURCES
____ Last Day of Sick Leave (if needed)
____ Insurance/TSA Notice prepared and dispersed
____ Resignation form completed and filed
____ Separation Notice prepared and dispersed
____ Employee letter with requested forms mailed on _________
____ HRMS information completed
Human Resources Representative Signature: ____________________________________ Date:____________________________
Copy Distribution:
Dept. of Human Resources
Finance
School/Dept.
Employee
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Parent category: Business