ࡱ> ac^_` ~bjbj)) 4CgCg" 1  8LL,N~D]$+++++++$..0h+Qy"+_,%%%R8+%+%%%LT7p%{+,0L,%L1C L1%L1%h%++$L,L1 X v:  SEPARATION FROM EMPLOYMENT TRANSFER - LEAVE OF ABSENCE EMPLOYEE: BANNER ID: 790- DEPARTMENT: JOB TITLE & POSITION NO:  FORMCHECKBOX  PERMANENT  FORMCHECKBOX  FULL-TIME  FORMCHECKBOX  TEMPORARY  FORMCHECKBOX  PART-TIME  FORMCHECKBOX  RESIGNATION  FORMCHECKBOX  TERMINATION  FORMCHECKBOX  RETIREMENT  FORMCHECKBOX  TRANSFER REASON CODE:  FORMTEXT       LAST DAY WORKED:  FORMTEXT       If reason code is TR (Transfer) please indicate University Dept. transferred to: PRIMARY REASON FOR LEAVING: BB  Better benefits IA  Invol. Sep after Probation Period RN Retirement, normal BP Better pay IW Invol. Sep w/in Probation Period RS Return to school CG Career Growth/promotional opportunity MO Moving TE Temp employment ended DE Death NS No Show TR Transfer to another ϻ Dept FC Family Circumstances PM Poor Management WL Workload, too little FE Funding Ended/Layoff QT Quit, no reason WM Workload, too much HR Health Reasons (self, family) RE Retirement, early   FORMCHECKBOX  LEAVE OF ABSENCE WITHOUT PAY REASON CODE:  FORMTEXT       LEAVE BEGIN DATE:  FORMTEXT       LEAVE END DATE:  FORMTEXT       DI  Discretionary Leave MI  Military WC  Workers Comp w/ Benefits FM  Family Medical Leave ED  Educational PS Public Service WN Workers Comp w/o Benefits SN Sabbatical MAILING OR FORWARDING ADDRESS SEND FINAL/TERMINATION PAYCHECK TO: (Per Employee Request for W2 also)  FORMCHECKBOX  Address  FORMCHECKBOX  Bank ACKNOWLEDGEMENT THAT EXIT ASSESSMENT (PAGE 2) WILL BE COMPLETED BY LAST DAY WORKED: ____________________________ __________ ___________________________ __________ Supervisor/Dept. Head Date Dean/Director Date PLEASE SEND THE SEPARATION/TRANSFER/LEAVE FORM (PAGE 1) TO HϻAN RESOURCE SERVICES IN LOMMASSON 252 AS SOON AS POSSIBLE. THANK YOU.  October 2020 SEPARATION FROM EMPLOYMENT-TRANSFER-LEAVE OF ABSENCE EXIT ASSESSMENT CHECKLIST EMPLOYEE NAME: BANNER ID: 790- SEPARATION DATE: DATE: Each separating employee and their supervisor must review each item listed on this form. If an item does not apply, mark it N/A. If a transaction occurs, the employee and the supervisor must initial the transaction upon completion. The Exit Assessment Checklist should be taken to the ϻ Police Department if the employee has University keys issued to them. The ϻ Police Department will verify the return of all university issued keys on the checklist. After completing the checklist the employee and the supervisor must sign and date the form and send it to Human Resource Services for inclusion into the exiting employees personnel file. TRANSACTIONEmployee INITIALSSupervisor INITIALSINFORMATION TECHNOLOGY Telephone credit cards returned Banner account closed Email Account closed (Retiree account remains open unless otherwise requested) Cell phone(s) and electronic devices returnedϻ POLICE DEPARTMENT Griz Card access to all ϻ doors revoked All University keys returned  To be completed by the ϻPD: Verification of returned keys signature and date: __________________________ All traffic fines paid ϻ parking permit. If you chose payroll deduction and have a balance remaining on your account will be chargedBUSINESS SERVICES IF YES TO ANY QUESTION BELOW, SEND A COPY TO BUSINESS SERVICES.  Does the employee have a Banner Finance Account?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Is the employee a Petty Cash or Change Fund Custodian?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Does the employee have a ProCard or Costco Card?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoHRS BENEFITS CONSULTATION: Call 406-243-4238 or 406-243-6766 Long Term Care Insurance Faculty/Staff fee waiver reimbursement processed Flexible Spending Account (s) closed COBRA explained Retirement options discussed  We acknowledge that all University property has been returned and the exit process completed. Employee Signature: _________________________________________________Date: __________________ Supervisor Signature: ________________________________________________ Date: __________________ Human Resource Services: ____________________________________________ Date: __________________ Please submit this form to  HYPERLINK "http://www.umt.edu/hrs/" HϻAN RESOURCE SERVICES in Lommasson 252. Questions? 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