Employee
Separation Report

Employee Separation Report

Please complete the form below.

Last Name

First Name

Department

Last 4 digits of social security number

Employee Number

Effective Date

Type of Seperation

Resignation (attach letter of resignation)

Retirement

Mutual Agreement

Dismissal

Lay-off (approximate return date)

Other

Date of Notice Given

By

Reason for Separation

Absenteeism/Lateness

Health

Reduction in Forces

Changing Job

Incompetence

Personal Reason

Other

Remove from schedule week beginning

Overall Evaluation of Employee while at Zehnder's

Attendance

Excellent

Good

Satisfactory

Improvement Needed

Unsatisfactory

Cooperation

Excellent

Good

Satisfactory

Improvement Needed

Unsatisfactory

Work Quantity

Excellent

Good

Satisfactory

Improvement Needed

Unsatisfactory

Job Knowledge

Excellent

Good

Satisfactory

Improvement Needed

Unsatisfactory

Work Quality

Excellent

Good

Satisfactory

Improvement Needed

Unsatisfactory

Recommendation

Without Reservation

With Some Reservation

Would not Recommend

Rehire

Yes

No

Other

Final Paycheck

Self Pick-up

Mail

Hold in Office

Supervisor's Comments

Supervisor's Signature (type first and last name)

Date

Witness's Signature (type first and last name)

Date

Employee's Comments

This Separation has been Reviewed with me

I give permission to use this report as reference for prospective employers.

I do not give permission to use this report as a reference for prospective employers.

Employee's Signature (please type first and last name)

Date

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Employee
Separation Report

Employee Separation Report

Overall Evaluation of Employee while at Zehnder's

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