Fillable Printable Noncomplete Employee Separation Form

Noncomplete Employee Separation Form

EMPLOYEE SEPARATION FORM

Client Name: ______________________________________________________________________________

Employee Name:

SSN:

Position:

State in which Employee Worked: First Day Worked: ___________________________

Last Day Worked: Client Phone: ____________________________________________

Address: __________________________________________________________________________________

Completed

By (PRINT NAME):

Date:

Client Signature:

Reason For Separation

Place a check next to the reason that most appropriately applies for the separation. Check only one.

Quit Discharge ‐ (Must give details below)

( ) 2 ‐ No Reason Given Name of person who discharged employee?

( ) 3 ‐ Quit (Please explain below) What was the final incident?

( ) 4 ‐ Mutual agreement (not protestable)

Required ‐ attach written warnings and any backup

( ) 5 ‐ Failed to return from leave of absence

( ) 6 ‐ Three days unreported absence ( ) L ‐ Intoxicated on the job (Pinnacle HR Approval)

Give dates:

( ) M ‐ Left work without permission

( ) 7 ‐ Accepted other employment

( ) N ‐ Excessive absences & tardiness

( ) 8 ‐ To leave area ( ) O ‐ Fighting on company property

( ) 9 ‐ Personal ( ) P ‐ Refused to perform job duties

( ) B ‐ Transportation problem ( ) Q ‐ Destruction of company property

( ) C ‐ Childcare problem ( ) R ‐ Violation of company policy

( ) D ‐ Due to medical reasons ( ) S ‐ Insubordination

( ) E ‐ Dissatisfied (Please explain below) ( ) T ‐ Sleeping on job

( ) F ‐ Walked off job ( ) U ‐ Inability to perform job (not protestable)

( ) G ‐ Assignment completed

( ) V ‐ Violation of safety rules

( ) H ‐ Attend school ( ) X ‐ Improper conduct

( ) I – Left to work for another franchise owner ( ) Y ‐ Falsification

Lack of Work

( ) J ‐ Lack of work

( ) K ‐ Location closed

EXPLANATION (PROVIDE DETAILS FOR GROSS MISCONDUCT OR VIOLATION OF WORK RULES BY THE EMPLOYEE)

Submitting Attachments: YES NO (required for terminations)

Provide all supporting performance documents (Counseling Statements) for unemployment purposes.

10/2014