Form Sf-14r - Employee Separation Notice Form - Northwestern State University printable pdf download

Northwestern State University

Attachment #1

Employee Separation Notice & Exit Interview Report (SF-14R)

(Copy must be submitted to Business Affairs - Human Resources Section and to Information Systems Director)

Date: _____________________

Budget Unit Head:________________________________________

Budget Unit Title:______________________________________

Employee: _______________________________________________ Position Title: _____________________________________ SSN# _________________________

Computer User ID _______, _______, _______, _______, _______

Separation Date: __________________

Last Day Worked: __________________

Please accept my ________________________________ (resignation, retirement, etc.) at the close of business ______________________ (date). My reason for separation is

___________________________________________________________________________________________________________________________________________

Reasons for Separation

Work Satisfaction: Incentives

Movement Within State Government

Relations with Personnel

Living Environment

___1. Insufficient Pay

___13. To accept new probational appointment

___18. Relations with fellow

___24. Transportation

___2. Better job - private industry

___14. To accept classified/Unclassified

employees

___25. Housing facilities

___3. Lack of Promotional

appointment

___19. Relations with Supervisor

___26. Living Costs

opportunities

___15. Transfer out (lateral, promotion,

___27. Locality

___4. Job security

demotion to another agency)

___28. Reasons unknown

___5. Work not interesting

___29. Home responsibilities

___30. Business responsibilities

Personal Reasons

Retirement

Work Conditions

___31. Other

___6. Poor health

___16. Disability

___20. Shift work

___7. Maternity

___17. Regular

___21. Excessive work

Unemployment Insurance Information

___8. Marriage

___22. Insufficient work

____32. I have another position/job

___9. Moving to another area

___23. Physical condition of work

____33. I do not have another position/job

___10. To go to school

___11. Military service

___12. Transfer

Comments and remarks: _______________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

Employee signature: __________________________________________________ Date: _________________

*******************************************

Supervisor and Budget Unit/Division Head or Vice President Section

If voluntary, check the item below which indicates the type of voluntary separation:

Involuntary

____ Resignation

____ Transfer

____ Completing Temporary Appointment ____ Layoff

____ Termination of appointment

____ Retirement (Disability)

____ Separation (Military)

____ Removal for Cause

____ Separation (Probationary)

____ Retirement (Optional)

____ Termination

____ Retirement (Age)

Supervisor:

How long have you supervised the employee? ______ Comments concerning loss of employee: ________________________________________________________________

________________________________________________________________Supervisor’s signature: ________________________________ Date: ___________________

Budget Unit Head:

Comments concerning loss of employee: ___________________________________________________________________________________________________________

_______________________________________________Budget Unit/Division Head signature: _________________________________________ Date: ________________

Vice President:

Comments concerning loss of employee: ___________________________________________________________________________________________________________

_____________________________________________Vice President signature: ___________________________________________________ Date: __________________

**************************************

Business Affairs - Human Resources Section

Employee’s Years of State Service _________Here ________Other _________Total;

Employee’s Date of Birth: ________________________

In connection with his/her separation, the employee has had reviewed with him/her and given relevant information concerning the following subjects: (check all items that apply)

___ Leave

___ Termination Pay

___ Group Life Insurance

___ COBRA

___ Group Hospitalization

___ Payroll Deductions

___ Rights of Employee Leaving for Military Service

___ Retirement

___ Re-employment ___ Other (list) _______________________________________

This is to certify that the above listed information has been explained, and I fully understand my responsibilities.

___________________________________________

_________________