Fillable Printable Employee Clearance Checklist
Fillable Printable Employee Clearance Checklist
Employee Clearance Checklist
To be completed by employee’s supervisor.
INSTRUCTIONS:For each question answered YES, select the appropriate column and follow related guidance beginning on Page 4.
For each question answered NO, no further action required except for questions 3, 13 and 35.
3. Please have the employee submit all travel vouchers and miscellaneous vouchers and return all outstanding vouchers before
supervisor's signature.
13. Please have the employee return all office materials before supervisor's signature.
35. Please notify Health Unit of departure for supervisor's signature.
Employee’s Name:
Supervisor’s Name:
Office/Division Code:
Complete the following questionnaire.
Supervisors should advise all clearance contacts, via e-mail,
at least 10 days in advance of a separating or reassigned
employee to allow time to collect items to be returned and to
allow time to resolve problems.
Separation Date:
Debrief Employee. Include privacy,
disclosure, and confidentiality
responsibilities.
Supervisor Responsibilities (Check off the two steps below as they are completed)
1. Was the employee issued a Government Purchase Card?
2. Was the employee issued a Travel Charge Card and/or a Fleet Card?
3. Has the employee submitted all travel vouchers, miscellaneous vouchers and returned any outstanding
travel advances?
4. Was the employee issued Calling/Phone Cards to be used at home, while traveling, or in an emergency?
5. Was the employee issued GETS to be used during COOP or a national emergency?
YESNO
YESNO
6. Was the employee issued Air Cards to be used during COOP or a national emergency?YESNO
YESNO
YESNO
YESNO
YESNO
YESNO8. Was the employee issued a cell phone and/or Blackberry?
7. Was the employee issued anything in support of COOP (e.g. COOP systems, COOP materials maintained
offsite to include policy, practice and procedural manuals)?
Employee Clearance Checklist
GENERAL SERVICES ADMINISTRATIONGSA 1655 (REV. 3/2012)
23. Do co-workers or managers need access to any of the employee's electronic files? (Permitted for 30 days)
GSA 1655 (REV. 3/2012) PAGE 2
22. Was the employee enrolled in the transit pass program and has unused subsidy funds
(transit, parking, other) to return?
21. Did the employee have a reserved parking space or parking pass/permit (e.g. Parking Space Number)?
20. Was the employee issued Office Keys (desk keys, file cabinet keys, possibly keys for storage)?
19. Was the employee issued access via key or controlled code to controlled areas (e.g., locked file cabinets,
storage rooms, key(s) to private office doors, etc)?
18. Was the employee granted access to the Fitness Center?
17. Was the employee issued a building access card other than a PIV card?
16. Was the employee issued a Government ID/PIV card and/or a Regional Access Badge/GSA Access Card?YESNO
YESNO
24. Was the employee currently receiving any benefits under the GSA Child Care Subsidy Program? YESNO
25. Did the employee receive any benefits under the Student Loan Repayment Program?YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO15. Was the employee granted RAS/VPN access?
YESNO
YESNO
YESNO
YESNO14. Did the employee have voice mail?
13. Did the employee return all office files, office supplies provided for telework and reference materials?
12. Was the employee issued property passes allowing them to remove government property from the facility?
11. Was the employee issued non-IT office equipment, software, or adaptive equipment provided by the government under
an arrangement or reasonable accommodation for use at home or other work arrangement, e.g. Telework?
YESNO
YESNO
10. Was the employee issued IT equipment (i.e., laptop, computer systems, work at home/telework systems, USB
thumb drives, external hard drives, cameras, cables, power cords, phone headsets, printers, accessories,)?
9. Was the employee issued any other equipment or tools that should be returned to the issuing division?
YESNO
YESNO
27. Do co-workers or managers need access to any of the employee's e-mails or e-mail archives?
26. Did the employee receive any relocation benefits from GSA?
GSA 1655 (REV. 3/2012) PAGE 3
DATE
DATE
SUPERVISOR'S SIGNATURE
EMPLOYEE SIGNATURE
Additional Notifications
YESNO
34. Does the employee have a Confidential, Secret, or Top Secret Clearance, which requires a security
debriefing?
YESNO
35. Was the Health Unit notified of the employee's last day?YESNO
36. Was the employee informed of the option to complete an exit interview or exit survey?
YESNO
33. Does the employee have an Official Passport?
YESNO
YESNO
YESNO
YESNO
YESNO
28. Did the employee have any official paper records/agency files in their possession that should be filed in
accordance with the GSA Records Retention Schedule (e.g. required receipts supporting travel vouchers)?
29. Did the preceding "clearance process" result in any indebtedness to the government (e.g., the employee
failed to turn in property or materials issued to them)?
30. Did the employee have a Continued Service Agreement (CSA)?
31. Is the employee in possession of a government Contracting Officer's Warrant?
32. Does the employee owe for any outstanding tuition related to a training agreement?
Question
Answered
YES for
number
Employee is Leaving GSA
Employee is Transferring to
Another GSA Region
Employee is Transferring to
Another Service/Staff Office
Employee has a Change in
Duties Due to Promotion/
Demotion/Reassignment
1
Collect/Destroy Card. Notify
Charge Card Coordinator to Cancel
Account
Collect/Destroy Card. Notify
Charge Card Coordinator to Cancel
Account
Determine if purchase card is still
required and if not, collect/destroy.
Notify Charge Card Coordinator of
need to cancel account. If needed,
notify Charge Card Coordinator of
Employee's Transfer.
Determine if purchase card is still
required and if not, collect/destroy.
Notify Charge Card Coordinator or
need to cancel account.
If needed, no action.
2
Collect/Destroy Card. Notify
Charge Card Coordinator to Cancel
Account
Collect/Destroy Card. Notify
Charge Card Coordinator to Cancel
Account
Notify Charge Card Coordinator of
Employee's Transfer.
No action.
3
Check Outstanding travel orders
and advances by contacting
Financial and Payroll Services
Division (816) 926-5497.
Check Outstanding travel orders
and advances by contacting
Financial and Payroll Services
Division (816) 926-5497.
Check Outstanding travel orders
and advances by contacting
Financial and Payroll Services
Division (816) 926-5497.
No action.
4
Notify local CIO Voice & Video
Services to Cancel the Card.
Notify local CIO Voice & Video
Services to Cancel the Card.
Notify local CIO Voice & Video
Services to Cancel the Card.
Determine continued requirement
for card. If unneeded in new
position, notify local CIO Voice &
Video Services to cancel the card.
5
Collect Card and return to GETS
Administration. If card is
uncollectible, please contact GETS
Administration at 866-NCS-CALL
(627-2255)
Collect Card and return to GETS
Administration. Call at 866-NCS-
CALL (627-2255)
Collect Card and return to GETS
Administration. Call at 866-NCS-
CALL (627-2255)
Determine continued requirement
for card. If unneeded in new
position, Collect Card and return to
GETS Administration. Call at 866-
NCS-CALL (627-2255).
GSA 1655 (REV. 3/2012) PAGE 4
INSTRUCTIONS: For each question answered YES, select the appropriate column and follow related guidance.
Question
Answered
YES for
number
Employee is Leaving GSA
Employee is Transferring to
Another GSA Region
Employee is Transferring to
Another Service/Staff Office
Employee has a Change in
Duties Due to Promotion/
Demotion/Reassignment
6
Collect Air Cards and return to local
IT support. If collection is
unsuccessful, notify the National
Payroll Branch (BCEC) at (816)
926-7548 Attn: Pay Ops Supervisor
to put a hold on final paycheck.
Collect Air Cards and return to local
IT support.
Collect Air Cards and return to local
IT support.
Determine continued requirement
for Air Cards. If unneeded in new
position, collect Air Cards and
return to local IT support.
7
Collect all COOP-related supplies,
equipment, and materials. If
collection is unsuccessful, notify the
National Payroll Branch (BCEC) at
(816) 926-7548 Attn: Pay Ops
Supervisor to put a hold on final
paycheck.
Collect all COOP-related supplies,
equipment, and materials.
Collect all COOP-related supplies,
equipment, and materials.
Determine continued requirement in
new position. If unneeded, collect.
8
Collect cell phone and/or Blackberry
and all accessories/passwords and
return to local IT support. If
collection is unsuccessful, notify the
National Payroll Branch (BCEC) at
(816) 926-7548 Attn: Pay Ops
Supervisor to put a hold on final
paycheck.
Collect cell phone and/or Blackberry
and all accessories/passwords and
return to local IT support.
Collect cell phone and/or Blackberry
and all accessories/passwords and
return to local IT support.
Determine continued requirement for
cell phone and/or Blackberry. If
unneeded in new position, collect
cell phone and/or Blackberry and all
accessories/passwords and return to
local IT support.
9
Collect equipment and return to
division stock. If collection is
unsuccessful, notify the National
Payroll Branch (BCEC) at (816)
926-5066 to put a hold on final
paycheck.
Collect equipment and return to
division stock.
Collect equipment and return to
division stock.
Determine continued need for
equipment. If unneeded in new
position, collect equipment and
return to division stock.
GSA 1655 (REV. 3/2012) PAGE 5
INSTRUCTIONS: For each question answered YES, select the appropriate column and follow related guidance.
Question
Answered
YES for
number
Employee is Leaving GSA
Employee is Transferring to
Another GSA Region
Employee is Transferring to
Another Service/Staff Office
Employee has a Change in
Duties Due to Promotion/
Demotion/Reassignment
10
Collect equipment and notify IT
Service Desk at 866-450-5250 to
pick up and return to inventory. If
collection is unsuccessful, notify the
National Payroll Branch (BCEC) at
(816) 926-7548 Attn: Pay Ops
Supervisor to put a hold on final
paycheck.
Collect equipment and notify CIO
Desktop support at 866-450-5250 to
pick up and return to inventory.
Collect equipment and notify CIO
Desktop support at 866-450-5250 to
pick up and return to inventory.
Determine continued need for
equipment. If unneeded in new
position, collect equipment and
notify CIO Desktop support at
866-450-5250 to pick up and return
to inventory.
11
Collect and return to appropriate
office. If collection is unsuccessful,
notify the National Payroll Branch
(BCEC) at (816) 926-5066 to put a
hold on final paycheck.
Collect and return to appropriate
office.
Collect and return to appropriate
office.
No action.
12
Collect and Destroy pass. Collect and Destroy pass. Collect and Destroy pass.
Determine continued need for pass
in new position. If unneeded,
collect and destroy.
13
Collect and return to appropriate
office. If collection is unsuccessful,
notify the National Payroll Branch
(BCEC) at (816) 926-5066 to put a
hold on final paycheck.
Collect and return to appropriate
office.
Collect and return to appropriate
office.
No action.
14
Verify PIN Number to access
account.
If successful, change PIN
immediately. If unsuccessful,
contact the IT Service Desk and
request PIN be reset immediately.
Notify organizational Points of
Contact as to whether phone
number should remain active or be
disconnected.
Verify PIN Number to access
account.
Notify organizational Points of
Contact as to whether phone
number should remain active or be
disconnected.
Verify PIN Number to access
account.
Notify organizational Points of
Contact as to whether phone
number should remain active or be
disconnected.
No action.
GSA 1655 (REV. 3/2012) PAGE 6
INSTRUCTIONS: For each question answered YES, select the appropriate column and follow related guidance.
GSA 1655 (REV. 3/2012) PAGE 7
INSTRUCTIONS: For each question answered YES, select the appropriate column and follow related guidance.
Question
Answered
YES for
number
Employee is Leaving GSA
Employee is Transferring to
Another GSA Region
Employee is Transferring to
Another Service/Staff Office
Employee has a Change in
Duties Due to Promotion/
Demotion/Reassignment
15
Contact IT Service Desk and close
Account.
Contact IT Service Desk and close
Account.
Contact IT Service Desk and close
Account.
Determine need for continued
access. If unneeded in new
position, contact IT Service Desk
and close Account.
16
Attempt collection of card. If
successful, return to Security Office
to the Regional Credentialing
Officer. If unsuccessful, notify
Security that attempts to collect the
card failed and notify the National
Payroll Branch (BCEC) at (816)
926-5066 to put a hold on final
paycheck.
No action. No action. No action.
17
Collect both cards and return to
local Security. If unsuccessful, call
Security and request that the
employee's accesses be cancelled
immediately and notify the National
Payroll Branch (BCEC) at (816)
926-5066 to put a hold on final
paycheck.
Collect both cards and return to
local Security.
Collect both cards and return to
local Security.
No action.
18
Notify Fitness Center of employee's
departure.
Notify Fitness Center of employee's
departure.
No action. No action.
19
Collect keys and return to office
inventory. If uncollectible, contact
management regarding having
locks changed.
Collect keys and return to office
inventory.
Collect keys and return to office
inventory.
Determine continued need. If
unneeded in new position, collect
keys and return to office inventory.
Question
Answered
YES for
number
Employee is Leaving GSA
Employee is Transferring to
Another GSA Region
Employee is Transferring to
Another Service/Staff Office
Employee has a Change in
Duties Due to Promotion/
Demotion/Reassignment
20
Collect keys and return to office
inventory. If uncollectible, contact
management regarding having locks
changed.
Collect keys and return to office
inventory.
Collect keys and return to office
inventory.
Determine continued need. If
unneeded in changed position,
collect keys and return to office
inventory.
21
Notify issuing office/South Field
Office of retirement/employee's
departure.
Notify issuing office/South Field
Office of retirement/employee's
departure.
No action.
If employee still qualifies, do
nothing. If not, Notify issuing office/
South Field Office of retirement/
employee's departure.
22
Attempt collection of unused
benefits and return to Transit
Benefit Coordinator. If collection is
unsuccessful, notify the National
Payroll Branch (BCEC) at (816)
926-5066 to put a hold on final
paycheck.
Collect unused benefits and return
to Transit Benefit Coordinator.
No action. No action.
23
If YES, send e-mail to
The message should include the
names and locations of files and the
names of those individuals requiring
access.
If YES, send e-mail to
The message should include the
names and locations of files and the
names of those individuals requiring
access.
If YES, send e-mail to
The message should include the
names and locations of files and the
names of those individuals requiring
access.
Not Applicable.
24
If YES, Contact the Financial and
Payroll Services Division at (816)
926-7063 to ensure that benefits do
not continue after employee
separates from GSA.
No actionNo action No action
25
If YES, did the employee fail to
meet the conditions of their Student
Loan Repayment Service
Agreement? If YES Collect
repayment for benefits received
from the employee. Repayment
should be sent to the Financial and
Payroll Services Division, Financial
Operations Disbursement Branch
(BCEB)
No actionNo actionNo action
GSA 1655 (REV. 3/2012) PAGE 8
INSTRUCTIONS: For each question answered YES, select the appropriate column and follow related guidance.
Question
Answered
YES for
number
Employee is Leaving GSA
Employee is Transferring to
Another GSA Region
Employee is Transferring to
Another Service/Staff Office
Employee has a Change in
Duties Due to Promotion/
Demotion/Reassignment
26
If YES, Did the employee fail to
meet the conditions of their Service
and Reimbursement Agreement -
Moving Expense Allowances? If
YES, Check with the Financial and
Payroll Services Division at (816)
926-7012 to determine the amount
the employee is required to pay
back to GSA. Collect repayment
from the employee. Repayment
should be sent to the Financial and
Payroll Services Division, Financial
Operations and Disbursement
Branch (BCEB).
No actionNo actionNo action
27
If YES, send e-mail to
to request access.
Access to an active employee's mail
file is not permitted. Have
employee provide copies of work
related e-mails prior to departure.
Access to an active employee's mail
file is not permitted. Have
employee provide copies of work
related e-mails prior to departure.
Access to an active employee's
mail file is not permitted. Have
employee provide copies of work
related e-mails as needed.
28
Collect records and file
appropriately.
Collect records and file
appropriately.
Collect records and file
appropriately.
Collect records and file
appropriately.
29
Notify the National Payroll Branch
(BCEC) at (816) 926-5066 of
indebtedness.
Notify the National Payroll Branch
(BCEC) at (816) 926-5066 of
indebtedness.
Notify the National Payroll Branch
(BCEC) at (816) 926-5066 of
indebtedness.
Notify the National Payroll Branch
(BCEC) at (816) 926-5066 of
indebtedness.
GSA 1655 (REV. 3/2012) PAGE 9
INSTRUCTIONS: For each question answered YES, select the appropriate column and follow related guidance.
Other Office
Instructions
INSTRUCTIONS: For each question answered YES, select the appropriate column and follow related guidance.
Question
Answered
YES for
number
Employee is Leaving GSA
Employee is Transferring to
Another GSA Region
Employee is Transferring to
Another Service/Staff Office
Employee has a Change in
Duties Due to Promotion/
Demotion/Reassignment
30
Notify the Continued Service
Agreement (CSA) Clearance Officer
Notify the Continued Service
Agreement (CSA) Clearance Officer
Notify the Continued Service
Agreement (CSA) Clearance Officer
Notify the Continued Service
Agreement (CSA) Clearance Officer
31
Supervisor should collect the
Contracting Officer's Warrant from
the Employee
No action.No action.No action.
32
If YES, did the employee fail to meet
the conditions of their training
agreement? If YES Collect
repayment for training received from
the employee. Repayment should
be sent to the Financial and Payroll
Services Division, Financial
Operations Disbursement Branch
(BCEB)
No action.No action.No action.
33
Collect and return to appropriate
office. If collection is unsuccessful,
notify the National Payroll Branch
(BCEC) at (816) 926-5066 to put a
hold on final paycheck.
Collect and return to appropriate
office.
Collect and return to appropriate
office.
No action.
34
Notify Security Office of employee's
departure
No action.No action.No action.
35
Notify Health Unit of employee's
departure.
Notify Health Unit of employee's
departure.
No action. No action.
36
No action. No action.No action.No action.
GSA 1655 (REV. 3/2012) PAGE 10
