Termination Documentation Form

This document is a comprehensive form for documenting employee terminations, covering reasons, employee feedback, exit procedures, and payroll details.

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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

Explain the reason given above in detail: ________________________________________

______________________________________________________________________

Employee's stated reason for termination: ____________________________________

______________________________________________________________________

Is the employee eligible for rehire? ☐ YES ☐ NO

If not eligible or only under certain conditions, explain: ___________________________

______________________________________________________________________

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 byDateKeysEmployee ID CardLaptop/computerCell phoneCompany credit cardOther:

Payroll

AmountDateFinal paycheckSeverance payVacation (# 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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