EMPLOYEE SEPARATION FORM

Last Name

First Name

Department

Effective Date

Type of Separation
Resignation - if resigned, attach letter of resignation

Retirement
Mutual
Dismissal
Lay-off
Other

If laid off, approximate return date

Other Separation Reason

Date of notice given

Notice given by

Reason for separation - check one
Absenteeism or Lateness
Health
Other
Reduction in Forces
Changed Job
Incompetence
Personal

Remove from schedule week beginning

OVERALL EVALUATION OF EMPLOYEE WHILE AT ZEHNDER'S

Attendance
ExcellentGoodSatisfactoryImprovement NeededUnsatisfactory

Cooperation
ExcellentGoodSatisfactoryImprovement NeededUnsatisfactory

Work Quantity
ExcellentGoodSatisfactoryImprovement NeededUnsatisfactory

Job Knowledge
ExcellentGoodSatisfactoryImprovement NeededUnsatisfactory

Work Quality
ExcellentGoodSatisfactoryImprovement NeededUnsatisfactory

Recommendation
Without Reservation
With Some Reservation
Would Not Recommend

Rehire?
Yes
No

Supervisor's Comments

Supervisor's Signature - Please type first and last name

Employee Comments

Today's Date

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 Signature - Please type first and last name