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Employee Exit Interview Checklist Form

This exit checklist documents an employee's termination from a company by listing the employee's name, department, manager, hire and termination dates, forwarding address, items to return such as keys and ID cards, final paycheck details including pay date and amounts for final pay, severance if applicable, vacation payout, who terminated the employee in the payroll system and the reason for termination, whether they are eligible for rehire, benefits termination details including explaining COBRA and HIPPA options and notification deadlines, and memberships and periodicals to be canceled or transferred along with verification dates.

Uploaded by

Saad Al-Subaie
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
4K views

Employee Exit Interview Checklist Form

This exit checklist documents an employee's termination from a company by listing the employee's name, department, manager, hire and termination dates, forwarding address, items to return such as keys and ID cards, final paycheck details including pay date and amounts for final pay, severance if applicable, vacation payout, who terminated the employee in the payroll system and the reason for termination, whether they are eligible for rehire, benefits termination details including explaining COBRA and HIPPA options and notification deadlines, and memberships and periodicals to be canceled or transferred along with verification dates.

Uploaded by

Saad Al-Subaie
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Company Name

Exit Checklist
Name:

Department:

Manager:

Termination date: Hire date:

Forwarding address:

Interviewed By: Date:


Exit Interview
Questionnaire and synopsis reviewed and filed. Date:

Returned Keys: Date:


Items ID card: Date:

Final paycheck Amount: Date:

Severance pay Amount: Date:

Vacation (days: ) Amount: Date:

Terminated in system By: Date:


Payroll
Reason:

Eligible for rehire? Yes No

COBRA & HIPPA explained Health terminated 401(k) terminated


Benefits
COBRA notification deadline: COBRA notification date:

Memberships: Date:
Canceled or
Periodicals: Date:
Transferred
Verified by: Date:

Provided by the Society for Human Resource Management.


This is a sample template. Please consult with your legal counsel before adopting any new policy.

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