Clear Form
Instructions
TERMINATION/RETIREMENT FORM
This form is used to process the termination or retirement of a DOF, HR, or PPPL staff member. Complete both sections. To insure correct payment for the final day of work, be sure to fill in both date fields in Section II.
Current Staff: DOF Staff HR/PPPL Monthly Staff HR/PPPL Biweekly Staff
Correction Explain: _________________________________
SECTION I. EMPLOYEE INFORMATION
Employee Name: ____________________________________________________________________________
Last Name First Name MI
Empl ID: ___________ Dept # ________ Department: _______________________ Business Unit: (drop down) Select One
SECTION II. TERMINATION/RETIREMENT INFORMATION
Last Day Worked/Paid: __________________
MM/DD/YY
Effective Date (day after last day worked/paid): ___________________
MM/DD/YY
Reason for Termination or Retirement: (drop down) Select One If OTHER is selected, please provide explanation: _________________________________________________ Number of vacation HOURS earned but not taken (Not Days): ________________ Lump Sum Severance: $_________________ Charge Severance to Account # ___________________
Street
CLICK here for Termination Reason Descriptions
Forwarding address/phone#___________________________________________________________________ _________________________________________________________________________
City Phone # State Zip
_________________________________ DOF only: Evaluation of total contribution (brief summary of the quality of the work; contribution to the project; recommendation as to future employability).
Comments: __________________________________________________________________________ _______________________________________
Authorized Department Signature ___________________________________ Print Name
Fax or mail to the Office of the Dean of the Faculty or your Office of Human Resources: • Office of the Dean of the Faculty – 8-2168, 9 Nassau Hall • Main Campus HR – 8-2420, 1 New South • Library HR – 8-0454, Firestone Library • PPPL Human Resources – 243-2050, MS33 C-Site
____________________________________
Authorized DOF/HR/PPPL Signature Date
Date
3/2008