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 RetirementExplain 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
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: ____________________________________________________
If you often open multiple tabs and struggle to keep track of them, Tabs Reminder is the solution you need. Tabs Reminder lets you set reminders for tabs so you can close them and get notified about them later. Never lose track of important tabs again with Tabs Reminder!
Try our Chrome extension today!
Share this article with your
friends and colleagues.
Earn points from views and
referrals who sign up.
Learn more