Fillable Printable Employee Exit Clearance Checklist Form - University of Texas at Brownsville

Employee Exit Clearance Checklist Form - University of Texas at Brownsville

Human Resources

UTB at The Woods – 451 E. Alton Gloor ♦ Brownsville, Texas 78526 ♦ Phone: 956-882-8205 ♦ Fax: 956-882-7476

THE UNIVERSITY OF TEXAS AT BROWNSVILLE

Employee Exit Clearance Checklist

This form should be completed between the hours of 8:00 a.m. to 4:00 p.m. Monday through Friday or before your last

working day. Please call 882-8205 to schedule exit interview.

Please print.

Employee’s Name: _____________________________ Employee’s I.D. #: _____________

Department Name

Account #

FTE%

Termination Date

Last Working Day: __________________

Employee Section:

1. Are you going to work for another State Agency in the State of Texas? Yes No

2. Are you going to work for a School District? Yes No

3. If you answer “Yes” to question 1 or 2, please provide the following information:

____________________________________________ _____________________

Name of Agency/School District Date of Employment

Forwarding Address, Telephone #, and Email Address:

Address: _____________________________________

_____________________________________

Telephone: ( _____ ) _____________________________

Email: _____________________________________

4. Any absences during the last month of work? Yes No If yes, provide absence reports and/or timecard.

Direct Deposit Program

5. I want my Final payment to be Direct Deposit? Yes No Cancel Direct Deposit after (date) _________________

If not on Direct Deposit, what arrangements would you like to make for your last paycheck and your vacation settlement

if applicable:

Mail

Pick-up at (specify department) __________________________________________________________________

Other (specify special instructions) ________________________________________________________________

6. Authorization Signatures for

Department

Location

Phone

Signature

Employing Department Supervisor

Campus Police (keys)

Campus Security

Center:

One-Stop Shop

(Main Building)

882-8232

Campus Police (parking permit)

Library and Research Services Desk

University Library

Floor

822-8221

Instructional and Client Support Services (ICSS)

(computer access, WebMail, SharePoint, etc.)

882-4357

Enterprise Application Services (DataTel, etc.)

Rusteberg 104A

882-6508

Central Receiving (Inventory)

UTB at The Woods

451 E. Alton Gloor

882-8804

Accounting and Finance Office Cashiers

(parking permit fines / other)

Purchasing Department (credit cards)

882-3822

Employee Development (to be completed by HR Representative/Specialist only):

7. Is Employee on Tuition Assistance? Yes No

If Yes, do we need to deduct from last paycheck and how much? Yes No Amount to deduct: $______________

8. Does Employee have any equipment? Yes No

HR Representative/Specialist: _______________________________________ Date: _______________________

Benefits Section:

9. Optional Retirement Program (ORP)

UT Brownsville will submit Termination/Vesting Letter to Carrier on File.

Teacher Retirement System (TRS)

I am requesting UT Brownsville to submit Request for Refund to TRS. Request for Refund form has been completed.

I am NOT requesting a Request for Refund from TRS.

10. Consolidated Omnibus Budget Reconciliation Act (C.O.B.R.A.)

Information was received on the benefits available under C.O.B.R.A and a C.O.B.R.A. application form was

completed and received with instructions that it is the terminating employee’s responsibility to complete the form if

he/she desires to continue coverage under C.O.B.R.A.

Health Insurance Portability and Accountability Act (HIPAA)

HR Benefits Representative: ______________________________________ Date: _______________________

Compensation Section:

Yes

Pending

Yes

Pending

Absence Report(s)

Termination Notice

Direct Deposit

Timecard

ID card

Vacation Settlement

Parking Permit

Last Paycheck

Resignation Letter

Other

Sick Leave Pool

Other

I certify that to the best of knowledge, all appropriate areas have been properly cleared. I understand that The University of

Texas at Brownsville reserves the right to request the restitution of or payment of any property or the settlement of any

outstanding obligations that might have been excluded from this clearance process.

Employee’s Signature: _______________________________________ Date: ______________________

Compensation Representative: ________________________________ Date: ______________________

Revised 1/24/2014