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

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

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

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

Attended your exit interview – for info about benefits- continuation after separation (if applicable) and to offer confidential comments?  

q Yes        q Not applicable

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

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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