Employee Separation Clearance Checklist in Word
I have attached employee separation clearance checklist in word format.
SEPARATION CLEARANCE
CHECKLIST
| Employee Name | PN[ Employee Ticket No.] |
| Department | |
| HAVE YOU reviewed & completed the Asset Tracking Form and returned to your Supervisor or Department Rep: | Employee Initials & Date | Authorized RepInitials & Date | |||
| All Keys? | q Yes q Not applicable | ||||
| ID Card? | q Yes q Not applicable | ||||
| Account Codes & Passes? | q Yes q Not applicable | ||||
| Computer/ Info Tech Equipment? | q Yes q Not applicable | ||||
| Telecommunications Equipment? Mobile? SIM card Telephone? S | q Yes q Not applicable | ||||
| Vehicles / Transport Equipment? | q Yes q Not applicable | ||||
| Parking Pass (to Transportation Dept)? | q Yes q Not applicable | ||||
| Library / Bookstore Materials? | q Yes q Not applicable | ||||
| Other Equipment & Materials? | q Yes q Not applicable | ||||
| Timesheets & Leave Reports? | q Yes q Not applicable | ||||
| Travel Expense Receipts & Reports? | q Yes q Not applicable | ||||
| Phone / Fax Or Other Usage Logs? | q Yes q Not applicable | ||||
HAVE YOU ALSO |
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| Given your Forwarding Address to your HR/Payroll Rep – so you will receive your annual W-2 income tax forms, etc.? |
q Yes q Not applicable |
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| If engaged in research as part of your job, contacted Research Administration to review research agreements, patents, intellectual property agreements, etc.? |
q Yes q Not applicable |
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| If working in a lab environment, contacted Environmental Health & Safety regarding the handling of controlled materials such chemicals, lasers, radiation, biohazards? |
q Yes q Not applicable |
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| Attended your exit interview – for info about benefits- continuation after separation (if applicable) and to offer confidential comments? |
q Yes q Not applicable |
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| Do you want to donate your excess annual leave (beyond the max 240 hours payout) to a specific person currently on the Shared Leave Program? | q Yes (Contact HR for info)
q No |
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HR Separation Clearance Form: 04/26/05
BACK PAGE completed by Supervisor, HR/Payroll Rep, & Dept Head à
SEPARATION CLEARANCE
CHECKLIST, page 2
| Employee Name | Campus ID |
| Home Department | |
SUPERVISOR and/or HR / PAYROLL REP:
| HAVE YOU: | Authorized RepInitials & Date | ||
| Terminated the individual’s long distance access codes? | q Yes q Not applicable | ||
| Terminated the individual’s access rights to all IT Systems? | q Yes q Not applicable | ||
| Terminated the individual’s signature authority on bank accounts (such as Foundation accounts) | q Yes q Not applicable | ||
| Collected from the individual all assets listed on Asset Tracking Form? | q Yes q Not applicable | ||
| Wage-in-kind adjustments accounted for? | q Yes q Not applicable | ||
| Forwarded materials as appropriate to HR? | q Yes q Not applicable | ||
| Cancelled any training scheduled but not yet incurred? | q Yes q Not applicable | ||
| Cancelled any travel scheduled but not yet incurred? | q Yes q Not applicable | ||
| Submitted appropriate separation action(s) through HR System prior to the payroll cutoff deadline for the final pay date? | q Yes q Not applicable | ||
| Set up an Exit Interview for the individual with
— HR Employee Relations
|
q Yes q Not applicable | ||
| Credit Card – Check pending expenses for clearance if any – Return the card to Accounts(?) | |||
| Put a “tickler” on your calendar for 1 month after the termination date to verify that all payroll transactions have cleared, and to terminate individual from the Leave System.
|
q Yes q Not applicable | ||
DEPARTMENT HEAD / DIRECTOR:
My signature certifies that all separation requirements for the individual have been satisfied.
Dept Head/ Director SIGNATURE |
Dept Head/Director Name, Printed | Date |
A copy of this completed form should be submitted for the individual’s permanent Personnel File
TO: HR Information Management
HR Use ONLY |
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