This is a report that outlines the details and circumstances of an employee’s termination
which is affirmed by a witness. The report specifies the reason for termination and
whether it was voluntary or involuntary. In addition, any supporting documentation can
be attached to this report. A witness can affirm this report by certifying that they were
present for the termination of the former employee and acknowledge the truth of the
information and documents provided. This report should be used by small businesses
or other entities that want to accurately record the details of an employee’s termination
in order to prevent liability.
[Instruction: Insert company logo/letterhead here.]
Termination Report with Witness Signature
Employee Name: _____________________________________________
Job Title: _____________ Termination Date: _______ Last Day Worked: _________
Employment Status: _________ [Instruction: Indicate full or part time, temporary, etc.]
Rate of Pay: _____________ Supervisor: _______________
Reason for Termination: __________________________________
[Comment: Employer should insert such details as whether or not such termination was
voluntary or involuntary, for cause (including any applicable details) or based on other
general factors, examples of which include workforce reduction or layoff, among others.]
Information Discussed and Documents Provided: ______________________________
[Instruction: Employer should set forth a summary of information discussed and any
documents provided to terminated employee, including any and all state or federally
required information and documents.]
I was advised of my rights, if any pursuant to applicable COBRA and unemployment benefits as
well as all applicable federal and state rights applicable to terminated employees, if any.
I have read, understand and acknowledge receipt of a copy of this document and acknowledge
the receipt of all information and documents set forth herein.
Signature of Employee Date
-Employee Refused to Sign- Signature of Witness
Signature of Supervisor
I was present for the termination of the above-referenced employee, and hereby acknowledge the
information and documents provided to and discussed with the terminated employee is as set
Signature of Witness
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