Separation Notice - Free Download
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Separation Notice
NAME:
EMPLOYEE ID:
DEPARTMENT:
IMMEDIATE SUPERVISOR:
LAST DAY WORKED:
Instructions: This form is to be completed by the supervisor of the separating employee.
Supervisors should obtain employee’s signature and statement of reason for separation.
REASON FOR SEPARATION
In addition to checking reason for separation, give full explanation in space below. For example, if separation
is for "another job", indicate company name, starting date, and if they are leaving the area. If employee
does not give notice of voluntary separation, note when and how it was determined he/she was separated
and give any other relevant information.
VOLUNTARY
[] Without notice or reason
[] Another Job
[] Relocation
[] Illness
[] Working Conditions
[] Work Schedule
[] Other
[] Problem with Supervisor
[] Problem with Co-worker
[] Personal Problem
[] Return to School
[] Retirement
[] Refused Suitable Work
[] LOA - Did not Return
[] Pay
INVOLUNTARY
[] Absenteeism
[] Insubordination
[] Violation of Work Rules
[] Lack of Work
[] Other
[] Tardiness
[] Unsatisfactory Performance
[] Refusal to Follow Instruction
[] Job Eliminated or Changed
[] Disability
Explain reason given above in detail.
_______________________________________________________________________________________
_______________________________________________________________________________________
Employee's statement of reason for separation.
_______________________________________________________________________________________
_______________________________________________________________________________________
Is employee eligible for rehire [] YES [] If not eligible or only under certain conditions, explain:
_______________________________________________________________________________________
_______________________________________________________________________________________
I certify that the information furnished hereon is true and correct and authorize the release of this
document as requested.
_____________________________________________ __________
EMPLOYEE SIGNATURE DATE
_____________________________________________ __________
DEPARTMENT HEAD SIGNATURE DATE
