GEORGETOWN UNIVERSITY EMPLOYEE TERMINATION FORM
I. EMPLOYEE INFORMATION
NAME (L,F,M): PAY GROUP: PIN: GU ID: CLASS CODE: EFFECTIVE TERMINATION DATE: START DATE: LAST DATE ACTUALLY W ORKED: APT. #: PHONE:
DEPT. #:
STREET ADDRESS: CITY, STATE, ZIP: II. A. [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ B. [] [ ] [] [ ] [] [ ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 50
REASON(S) FOR TERMINATION
VOLUNTARY RESIGNATION Accepted Another Position Health Reasons In lieu of Dismissal In lieu of Dismissal During Probation Job Abandonment (no notice for three or more days) Personal/Family Obligations Probation Period Reduction in Pay and/or Hours Relocation Residency Completed Retirement pending School Working Conditions Other: Retired [Benefits Office use only] LAYOFF* 1 Lack of Funds* 2 Position Abolished* 3 Reduction in Force* C. [ [ [ [ [ [ D. [ [ [ [ [ [ [ [ [ ] ] ] ] ] ] ] ] ] 1 2 3 4 5 6 7 8 9 ] ] ] ] ] ] 1 2 3 4 5 6 DISMISSAL -- INVOLUNTARY* Absenteeism/Punctuality* Gross Misconduct* (Immediate Dismissal) Misconduct* Multiple Reasons* Probation Period* Work Performance* OTHER INVOLUNTARY SEPARATIONS Ended Temporary/Term Appointment Grant/Contract Expired Hired/Never Worked LOA, LTD Over One Year Required Shifts/Contract Not Met Tenure Requirements Not Met Worker's Compensation Over One Year Deceased* Other:
* TERMINATION FORM for separations designated with an asterisk must be hand carried to Human Resources and an INVOLUNTARY TERMINATION CHECK REQUEST must be hand carried to Payroll.
III. OFFERS OF EMPLOYMENT
Was the Employee offered another position within G.U.? [ ] Yes [ ] No If “Yes,” PIN of position offered: ____________ Date would have started: __________________ Employment Category: Wage Rate offered: $____________
IV. FINAL PERFORMANCE EVALUATION
IF EMPLOYMENT IS TERMINATED DURING THE EMPLOYEE'S PROBATION PERIOD, ATTACH A COPY OF A COMPLETED PROBATION FORM. IF THE EMPLOYEE HAS WORKED AND HIS/HER PERFORMANCE HAS SIGNIFICANTLY CHANGED SINCE HIS/HER LAST PERFORMANCE EVALUATION, ATTACH A NEW EMPLOYEE PERFORMANCE APPRAISAL FORM OR COMPARABLE DOCUMENTATION.
V. SIGNATURES
Employee/Date: Department Head/Date: Supervisor/Date: Human Resources/Date: [ ] Letter of Resignation [ ] Performance Appraisal / Probation Form [ ] Involuntary Termination Check Request (delivered directly to Payroll) [ ] Lump Sum Payment Form [ ] Notice of Layoff [ ] Other: Click here for instructions on how to complete this document. Click here for a list of procedures to follow when terminating an employee. 1/2007
VI. DOCUMENTS ATTACHED [ ] NO [ ] YES, as listed: