Pinecrest-Queensway Community Health Centre
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1USE PEN ONLY and PRESS HARD
Pinecrest-Queensway Community Health Centre
EMPLOYEE TERMINATION FORM/CHECKLIST
WHITE (Finance)
YELLOW (HR)
EMPLOYEE NAME:
POSITION:
PROGRAM:
LAST DAY OF ACTUAL WORK
DD / MM / YY
LAST PAID DAY
DD / MM / YY
The last day the employee is physically on the job
Last day employee is being paid including holidays and overtime.
RECORD OF EMPLOYMENT NEEDED:
YES
NO
If employee is continuing to work at PQ (either part-time or on another contract), do not request ROE.
REASON FOR ISSUING RECORD OF EMPLOYMENT:
NOTES:
(* include reason for ROE if “Other” - e.g. End of Contract)
Return to School
Quit
Leave of Absence
Pregnancy/Parental
Illness or Injury
Other*
Dismissal
GROUP BENEFITS:
CANCEL
CONTINUE
CONTINUE UNTIL
DD / MM / YY
The following is a checklist of items that should be considered by the supervisor/manager
upon termination. Please indicate which items you have completed and return this form to Finance and
provide any explanatory notes in the notes section.
FINANCIAL/HUMAN RESOURCE
JOB RELATED ITEMS
NOTES
RELATED ITEMS
Letter of resignation/leave received
Time sheets are up to date
and forwarded to Corporate Services
Current home address is on file
Vacation/overtime reconciled
with Finance
with finance
Associations/memberships
Petty cash reconciled/returned
are cancelled/transferred
to Finance
or replaced
PQ Property Returned
Outstanding expense reports
Keys returned to Custodian
_______
Cell phone returned to IT Staff
_______
Exit Interview Offered
Credit card returned to Finance
_______
Accepted ______
Declined ______
Equipment on Loan returned to IT
_______
Appointment made with Corporate
Other (specify):
_______
Services Manager regarding benefits
INFORMATION TECHNOLOGY ITEMS
COMPUTER:
Network Access
Delete
Retain until ________________
COMPUTER:
Email Account
Delete
Retain until _________________
Purkinje Account
Delete
Retain until _________________
If employee has access to more than one email account, please indicate what should be done with the other accounts.
COMPUTER: Email Distribution Lists
____________________________________
____________________________________
Please indicate which distribution lists this employee belongs to:
____________________________________
____________________________________
PHONE:
Current Voice Mail # ______
Current Extension # _______
Location: Room # __________________
Delete
Replace with name of current employee: ___________________________ (name)
SECURITY:
Swipe Card Returned and De-activated
NOTES:
________________________________
_________________________________
________________
Supervisor Signature
Manager Signature (required)
Date
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Parent category: Business