Employee: Date Termination Was Processed:
Department: Last Day Actually Worked:
Date Employee was Notified:
_______________________________
Employee's Performance was:
___ Exceptional
___ Met Standards
___ Had some concerns that were
discussed with employee
___ Deficient and despite
coaching, employee did not show
needed improvement
Anticipated Recall Date, if Known:
_______________________________
(Attach letter of resignation)
Date Supervisor was Notified:
_________________________________
_____ Quit - Reason:
_______________________________
_______________________________
_______________________________
_____ Retired
(Attach any supplementary documentation
including letter given to employee)
Reason for Involuntary Separation:
_________________________________
_________________________________
_________________________________
_________________________________
SUPERVISOR CLEARANCE
(Supervisor should put a check next to each item indicating it has been returned to the City OR mark N/A)
______ City owned cellular telephone and/or radio
______ Computer (laptop or PC)
______ Notification sent to Information Systems Department
that employee will be leaving and to change access
______ Tooele City ID Card (2 if includes recreation pass)
______ Gas card accounted for
______ Notification sent to Recorder's office to cancel pin
number for employee's gas card
______ Keys (office, vehicle, locker)
______ Clothing Not Issued for Personal Use
______ Tools
______ Computer Passwords
______ Procedure Books and Instruction Manuals (return
personnel policy manual to HR office)
______ Other: _______________________________
(For use by PAYROLL AND HUMAN RESOURCE DEPARTMENT)
_____ Compensatory Hours Paid Out
_____ Annual Leave Hours Paid Out
_____ Six Month Annual Leave Payback, if Applicable
_____ URS Notified of Change in Status
_____URS Benefit Notification Given to Employee
_____ 401K Termination
_____ 401K Rollover Guide
_____ COBRA Notification
_____ Life Insurance Conversion Option
_____ ESS Access Changed (Tyler User & Security on
Personnel Administration)
_____ Time Clock Plus Access Changed
_____ PEP Access Changed
_____ Notification sent to Information Systems Department
_____ Forwarding Address for W-2 Purposes:
__________________________________________________
Recommended for rehire: Yes __ No __ If no, explain why.
(An employee who resigns and desires to leave the city in good standing is expected to give a minimum of two weeks’ prior notice to be considered for re-hire).
Eligible for rehire: Yes __ No __ If no, explain why.
Resume Templates 1210 Document(s)
