Employee name: _______________________ Department:_________________
Termination date: _____________ Last day worked (if different): ______________
Forwarding address: __________________________________________________
Reason for Separation
| VOLUNTARY | □ Without notice or reason □ Another Job □ Relocation □ Illness □ Pay □ Working Conditions □ Work Schedule □ Enlisted in Armed Forces | □ Problem with Supervisor □ Problem with Co-worker □ Personal Problem □ Return to School □ Retirement □ Refused Suitable Work □ LOA - Did not return □ Other ___________________ |
| INVOLUNTARY | □ Absenteeism □ Insubordination □ Violation of Rules □ Lack of Work □ Other | □ Tardiness □ Unsatisfactory Performance □ Refusal to Follow Instruction □ Job Eliminated or Changed □ Involuntary Retirement |
Exit Interview
☐ Interviewed by: __________________________________ Date: _____________
☐ Exit questionnaire and synopsis reviewed and filed. Date: ___________________
Follow-up required ☐ Yes ☐ No
Items Received from Employee (enter n/a if not applicable)
| | Received by | Date |
| Keys | | |
| Employee ID Card | | |
| Laptop/computer | | |
| Cell phone | | |
| Company credit card | | |
| Other: | | |
| | | |
| | | |
| | Amount | Date |
| Final paycheck | | |
| Severance pay | | |
| Vacation (# of hours ____) | | |
| Other: | | |
Severance agreement offered? ☐ Yes ☐ No
Severance agreement/release of claims signed and returned? ☐ Yes ☐ No ☐ N/A
Benefits
☐ Health insurance terminated ☐ 401k plan terminated ☐ Life insurance terminated
☐ Disability insurance terminated ☐ Other: ________________________________
COBRA notification deadline: __________ COBRA notification date: _______________
HR Signature: __________________________________ Date:________
Printed name: ____________________________________________________
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