Service Letter Form Page 2
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2____ The employee was not directly involved providing services and/or
care to clients/patients/residents/children on a daily or frequent basis, but did
occasionally provide some care and/or services.
____ The employee did not provide services and/or care to clients/
patients/residents/children, but did have some contact with them.
____ The employee had no contact with clients/patients/residents/children.
____ This information is not available. (Please Explain.)
_______________________________________________________
B.
Reason for separation from service (please check one.)
____ Laid-off ____ Resigned
____
Resigned in lieu of discharge
____Discharged____ Abandoned Position
____ Other (Specify)_____________
____ Information not available (Explain) _____________________
C.
Information relating to employee's performance (please check all statements which
apply to this person and circle action/s taken.)
____ The employee was counselled, warned, reprimanded, suspended or discharged as a
result of reasonably substantiated incidents involving his/her violent behavior or
threats of violence in the workplace.
____ The employee was counselled, warned, reprimanded, suspended or
discharged as a result of reasonably substantiated incidents involving abuse of
patients/clients/residents/children.
____ The employee was counselled, warned, reprimanded, suspended or discharged as a
result of reasonably substantiated incidents involving negligence/neglect of
patients/clients/residents/children.
____ The employee was never counselled, warned, reprimanded, suspended or
discharged as a result of reasonably substantiated incidents involving violent
behavior
in
the
workplace,
abuse
or
negligence/neglect
of
patients/clients/residents/children.
____ Not applicable to this employee. (Please Explain.) _________________________
4.
(Optional) I would rehire this individual _____yes _____no
I hereby swear/affirm that the information provided above is a full and complete disclosure of the facts required, and that the
information is true and correct to the best of my knowledge and belief.
_____________________________________________________________
Printed name/title of person completing the form
___________________________
________________________
Signature
Date
This form is provided by the Delaware Department of Labor. Reproduce additional copies as needed.
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Parent category: Letters