Termination Report/non-Faculty Employees Form

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TERMINATION REPORT/NON-FACULTY EMPLOYEES
To be completed by the immediate supervisor.
Name_________________________________________ Southeast ID No. ____________________
Present Address____________________________________________________________________
Street
City
State
Zip
Forwarding Address_________________________________________________________________
Street
City
State
Zip
Effective Date of Forwarding Address
Department___________________________________ Job Title_____________________________
Date of Termination_______/_______/_______
Mo.
Day
Year
REASON FOR TERMINATION: (Mark appropriate reason; if resignation, letter or resignation from
employee must be attached)
[] A. Employee resignation – no reason given
[] I. Employee released – misconduct in
[] B. Employee resignation – leaving city
connection with work
[] C. Employee resignation – attend school
[] J. Employee released – refusal to work or
[] D. Employee resignation – military service
follow supervisory directions
[] E. Employee resignation – job dissatisfaction
[] K. Employee released – failure to report for work
[] F. Employee resignation – another job
[] L. Employee released – refusal to
[] G. Retirement
perform specific job requirements
[] H. Laid off
[] M. Other
If Box H, I, J, K, L or M was checked, then a written statement explaining the termination is required.
Please attach an additional sheet or type the statement on the back of this form. The statement should
list any date, times and/or actions taken for incidents which led to a termination. Please contact the
Director of Personnel Services if there are questions.
_________________________ _____/_____/_____ _________________________ _____/_____/_____
Employee Signature
Date
Department Head Signature
Date
_____________________________ _____/_____/_____
**Return one copy to Human Resources
Supervisor’s Signature
Date
To be completed by Human Resources
Classification
[] Administrative
[] Clerical
[] Professional
[] Skilled Craft
[] Technical
[] Service
Unused Vacation Hours ______________________ Date of Termination _____/_____/_____
Mo.
Day
Year
________________________________________ _____/_____/_____
Director of Human Resources
Date

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