Departing Employee Information Form

This form is to be used for departing employees.

Instructions:
Part “A” Appropriate Administrator instructions: (To be completed and hand delivered to Employee Services, Salazar 2078 within 24 hours of verbal or written notice). It is the Appropriate Administrator’s responsibility to ensure the information below is correct.
 Attach written letter of resignation from departing employee.
 Attach an absence report up to the employee’s last day on campus (if applicable).
 Complete all sections of Part “A” and have department clearance granted.
 Complete part “B” with departing employee.
 When both sections of form are completed, return form and attached letter of resignation to Employee Services, Salazar 2078.
Part “B” Departing employee instructions:
  • Complete wage pay out information.
  • Complete reason for separation.
Return form to Appropriate Administrator.
Note:
  • For temporary hourly intermittent staff and student employees, the Appropriate Administrator is responsible for completing the Campus Clearance form.
  • For staff annual renewable employees, Employee Services will complete the Campus Clearance form and schedule exit interview
* An exit interview is not necessary for temporary employees and is optional for all others.
Please direct questions regarding this form to 664-4127, fax 664-3196. Individuals in need of a telecommunications relay service may contact the California Relay Service at (877) 735-2929 TTY. For more information, please visit the Employee Relations and Compliance Services website at

Part “A”

Employee Name: /

Employee ID Number:

/ Department Name:
Appropriate Administrator: /

Department Contact and Campus Extension:

(Person to contact with questions)

Name:

Extension:

/ Department Clearance completed by:
Suggested Items to be Cleared by Department

(Pagers, cell phones, lap top PC, other PC, modem, media equipment, software, books, manuals, videos, office furniture/decorations (SSU vs. personal property), long distance calling cards, and Credit Card Purchasing Card)

Last Day On Campus (date):

(Consult With Departing Employee) / *Exit Interview to be Scheduled (call 4-4127 for an appointment)
Date:
Time:

Part “B”

Wage Pay Out Options and Instructions for Final Check

Pay Out All Accrued
Vacation & C.T.O. /

Remain on Payroll Until

all Accrued Vacation &

C.T.O. are exhausted

/ Remain on Payroll Through (date) & Pay Out Lump Sum Accrued Vacation & C.T.O. A request for deferral of all or a portion of accrued leave credits that extend to the next calendar year must be in writing to Payroll and Benefits and submitted 5 days before last day of employment. Only payment deferrals for the portion of leave credits that extend past the November pay period are eligible and will be paid to the employee by February 1.
Mail Final Check(s) to Address Below Hold Final Check(s) for Pick-up in Payroll and Benefits Office, Salazar 2078
Street Address:
City, State, Zip:
Reason for Separation:
Resignation (RSN) Retirement-Service (SRT) Retirement-Disability (DRT) End Temporary Appointment (END)

Employee Signature: ______ Date: ______

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