University of California, Davis Medical Center, Sacramento

UNIVERSITY OF CALIFORNIA, DAVIS HEALTH SYSTEM

EMPLOYEE SEPARATION FORM

(Not to be used for Employees who are moving from one department to another)

1.
Name / PPS ID # / PCN #

Is separating from employment at UCDHS for one of the following reasons:

Resignation Medical Separation

Retirement End of Casual Appointment

Dismissal Transfer to another UC campus

Release Other

Layoff

2.  Employee’s last day on pay status .

3.  Employee’s last actual day of work will be (was) .

4.  a. A copy of the employee’s letter requesting separation (Resignation, Retirement, Etc.) is attached.

b.  A copy of the letter initiating separation by the department is attached (RELEASE DURING PROBATION, DISMISSAL, ETC.)

c.  If unable to obtain a letter from the separating employee, then the supervisor must state reasons for the employee’s leaving. Be specific, oral reasons given by the employee to the supervisor should be incorporated into your statement.

5.  University property – Complete UCDHS Property Recovery and Access Termination Form.

6. Department Name Cost Center

Supervisor/

Representative Signature ______

White – Human Resources Yellow – Employee Dept. Pink – Employee

A1478 (12/05)