Employee name:  _______________________    Department:_________________

Termination date: _______________________ 

Type of Termination

☐ Voluntary:

☐ Received employee's resignation letter. (If verbal resignation, provided employee with a written confirmation of resignation).

☐ Exit interview scheduled.                    ☐ Exit interview completed.

☐ Involuntary:

☐ Provided employee with termination letter.

☐ Provided employee with severance agreement if eligible.

        ☐ Received signed severance agreement.

☐ Provided employee with WARN notice (if applicable).

Benefits

☐ Provided employee with termination/continuation of employment insurance benefits information (COBRA, life insurance, supplemental insurance, etc.)

☐ Checked FSA/HSA participation and informed employee of remaining funds and reimbursement deadlines, if applicable.

☐ Checked dependent care FSA participation and informed employee of remaining funds and reimbursement deadlines, if applicable.

☐ Checked PTO balance and informed employee of any remaining PTO and how it will be processed at termination of employment.

☐ Informed employee about retirement plan account options.

Compensation

☐ Provided notice of policy regarding any outstanding balances for money owed to company (e.g., educational loans/pay advances).

☐ Notified payroll department to process final paycheck.

☐ Informed payroll of any unused but earned PTO amounts due to the employee.

☐ Notified payroll to process severance pay and whether lump sum or salary continuation (if applicable).

Contracts/Legal

☐ Provided written notice to employee of any legal obligations that continue post-employment (e.g., noncompete/confidentiality agreements/employment contracts).

Immigration

☐ Notified company immigration attorney of termination if employee is on a temporary work visa.

Records

☐ Pulled personnel file to be stored with terminated employee files.

☐ Pulled Form I-9 to be stored with terminated employees' I-9s. 

☐ Obtained written authorization from employee to respond to employment verification requests.

Information Technology

☐ Disabled e-mail account.

☐ Removed employee's name from e-mail group distribution lists; internal/office phone list; website and building directories.

☐ Disabled computer access.

☐ Disabled phone extension.

☐ Disabled voicemail.

Facilities/Office Manager

☐ Disabled security codes, if necessary.

☐ Changed office mailbox.

☐ Cleaned work area and removed personal belongings.

☐ Collected the following items:

☐ Keys (☐ office ☐ building ☐ desk ☐ file cabinets ☐ other)

☐ ID card

☐ Building access card

☐ Business cards

☐ Nameplate

☐ Name badge

☐ Company cell phone

☐ Laptop

☐ Uniforms

☐ Tools

☐ Other _______________________

☐ Other _______________________

Form completed by:____________________________________ Date: _________________