Employee Termination List

EMPLOYEE TERMINATION LIST

Employee Information

Employee Name:   Employee ID:

Phone:   Email:

Position & Termination Summary

Job Title:   Department:

Reporting Manager:   Hire Date:

Effective Termination Date:   Last Day Worked:

Termination Type: Voluntary Involuntary Mutual Agreement Other:

Termination Reason & Narrative

Primary Reason (select all that apply):
Performance Misconduct Reduction in Force Attendance Policy Violation End of Temporary Assignment Resignation Retirement Other:

Final Pay, Benefits & Severance

Final Pay Date:   Accrued PTO Hours:   PTO Payout Amount:

Benefits Termination Date:    Continuation of benefits (COBRA/plan continuation) offered

Severance Provided: Yes   If yes, summarize terms:

Company Property Return Checklist

The following items were returned to company custody on or before the termination date. Check returned items and provide identifiers where applicable.

Company ID badge   Badge/ID Number:

Office keys / access card   Details:

Laptop / Computer   Make/Model/Serial:

Mobile phone / tablet   Serial/IMEI:

Company credit card   Last 4 digits:

Physical documents / storage devices / USB drives   Details:

Software accounts transferred/terminated   List accounts:

Other:

Collected by (name):   Date Collected:

Access Revocation / Systems

Confirm access revocations and system actions taken:

Active Directory disabled    Email account disabled    VPN access revoked

HRIS access revoked    Payroll access revoked    Finance systems reviewed

Accounts transferred to:   Revocation completed by:

Exit Interview & Employee Acknowledgement

Exit Interview Conducted: Yes   Interviewed By:   Interview Date:

Employee Acknowledgement of Receipt of Termination Notice and Final Pay Information:
Employee acknowledges receipt of termination notice, final pay and benefits information, and instructions for return of company property.
Employee Certification: I certify that the forwarding information provided above is true and that all company property identified as mine has been returned except as noted. I understand that applicable deductions and final pay processing will comply with law and company policy.
Employee Printed Name:

Employment History (Record)

Previous Employer 1 — Company Name:

Previous Employer 2 — Company Name:

Education

Professional References

Reference 1

Reference 2

Reference 3

Legal Notices & Disclosures

At-Will Employment: Unless governed by a written agreement signed by an authorized company representative, employment is at-will and may be terminated by either party at any time, with or without cause or notice. This form documents administrative actions and does not modify at-will status unless expressly stated in a separate signed agreement.

Equal Opportunity: The company prohibits unlawful discrimination and is committed to equal employment opportunity in all employment decisions. Termination decisions documented here are reported in accordance with company policy and applicable law.

Confidentiality & Return of Proprietary Information: The employee remains bound by any confidentiality, non-disclosure, and trade secret obligations. Unauthorized retention or disclosure of proprietary information may subject the employee to legal action. HR and management representatives certify that the employee was reminded of these obligations during the separation process.

HR Review & Administrative Clearance

Payroll Cleared: Yes   Benefits Notified: Yes   Legal Consulted: Yes

Unemployment Filing Required: Yes   If yes, reason/code:

Authorizations

Authorization to Contact Former Employers / Background: Authorized as required for administrative purposes in accordance with company policy and applicable law.

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