Notice Of Employee Separation Form Discharge
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1Notice of Employee Separation Form
DISCHARGE
Employee Name:__________________________________________
Social Security Number: ___________________________
Job Title: _______________________________________________
Last Day Worked: ________________________________
Company: _______________________________________________
Supervisor’s Name: _______________________________
Please complete the section and questions that apply to the employee’s employment with your company. Please attach any additional
documentation.
Absenteeism/Tardiness (W-X)
Did EE notify anyone of the absence or tardy on final incident:
Yes
No If yes, who:
What reason was given for the final absence/tardy:
Was EE given any written and/or verbal warnings for attendance prior to the last incident:
Yes
No
If yes, please list dates of warnings
Warning dates:
Did EE claim to be sick on final incident:
Yes
No
Did you request a Dr. note:
Yes
No
If yes, was a note received:
Yes
No
Was EE specifically told that they would be discharged if attendance did not improve:
Yes
No
Insubordination (M)
Did EE engage in inappropriate use of abusive language:
Yes
No
If yes, please explain in the Comments section
Did the EE refuse to follow reasonable and proper instructions:
Yes
No
If yes, please explain in the Comments section
Did EE refuse to accept an assignment to suitable work:
Yes
No
If yes, please explain in the Comments section
Violation of Company Policy or Procedure (N)
What rule or policy did EE violate:
Did the EE admit to the violation:
Yes
No
Had the EE been warned about violating this policy:
Yes
No
Is the policy in writing:
Yes
No
If yes, please attach policy
Was the EE given a copy of or reminded of the policy during previous warnings:
Yes
No
Were there witnesses to the violation:
Yes
No
If yes, did you obtain written statements:
Yes
No
Did the EE offer an explanation for the violation:
Yes
No
If yes, please explain in the Comments section of this Form
Dates of written and verbal warnings:
Was there a financial loss to your company:
Yes
No
If so, how much: $
Did EE agree to pay loss:
Yes
No
Had EE complied with the policy in the past:
Yes
No
Did EE acknowledge understanding of the policy:
Yes
No
Work Performance (Y,Z, a)
Did EE ever exhibit the ability to perform the job satisfactorily:
Yes
No
Length of time in current job:
Did EE receive warnings on job performance:
Yes
No
If yes, list dates and explain in the Comments section
Did EE offer an explanation for poor performance:
Yes
No
Was EE on probation at time of discharge:
Yes
No
If you believe the EE simply did not possess the ability to meet company standards, please indicate so in the Comment section of this Form
Lack of Work (1-5)
Was the EE laid off (Reduction in force):
Yes
No
Was the EE’s position eliminated:
Yes
No
Was it the end of the EE’s temporary employment:
Yes
No
Disharge: Comments Section
Completed By: __________________________________________________
Title: ______________________________
Signature: _______________________________________________________
Date: ______________________________
URGENT
: Please fax this form immediately to Sunwest Employer Services Inc., Fax Number: 602-778-9857
***PLEASE DISCARD THE OLD NOTICE OF EMPLOYEE SEPARATION FORMS**
th
3707 N. 7
St., #300, Phoenix, AZ 85014 Phone 602-778-9856 Fax 602-778-9857
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