Separation Or Termination Of Employment Record Form
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1Texas Tech University Health Sciences Center
Separation or Termination of Employment Record
Name of Employee ___________________________________________
R# __________________________
Employee’s Job Title ________________________________________
Date of Hire ____________________
School / Division __________________________
Department _____________________
Campus _______
Supervisor’s Name _______ _____________________________
Title ________________________________
Department Official’s Name ____________________________________ Title _________________________
(Director, Administrator, Chair, or other)
Requested effective date of separation or termination _____________________
Type of Separation or Termination
(please refer to HSC OP 70.31 and 70.__ for guidance):
Voluntary
Administrative
Misconduct
(Resignation with letter, use ePAF)
___ Reorganization
___ Behavior violations
___ Quit without notice
___ Reduction in force
___ Failure to perform
___ Failing to return from leave
___ Funding factors
___ Failure to achieve
___ Missing three consecutive shifts
___ Completion of work
corrective actions
without proper notice to dept.
___ Other
___ Other
___ Other
Explain:
Attachments:
___ Request to Separate or Terminate memorandum
___ Letter to Employee
___ Corrective Action documents
___ Most recent Performance Evaluation
___ Leave status confirmation from Leave Administrator
___ Other:
Separation or Termination Requested by:
Signature of Supervisor _______________________________________________
Date ______________
Signature of Department Official ________________________________________
Date ______________
(Director, Administrator, Chair, or other)
Please deliver the separation packet to local the Human Resources Director or designee for processing by HR.
For Human Resources Use Only
Review by Assistant Vice-President for Human Resources or designee:
Comments or recommendation:
Signature by AVPHR or designee ________________________________________
Date ______________
pproved by TTUS Chancellor, TTUHSC President or executive official
Separation or Termination a
designee:
Signature of executive official __________________________________________
Date ______________
HSC OP 70.31
April 29, 2015
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Parent category: Business