School Unit

Employee Name	First Day Worked	Last Day Worked

 

Employee's Position	Person Completing Form	Office Phone #
Rate of Pay (Hourly Amt or Salary)	Last Check Amount (Gross)	Last Check Date

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Reason for Separation  
 (Select from the appropriate drop down list)

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Voluntary Quit	Discharge/Misconduct/Other
100  None 101 Vol Quit - No Reason 102  Personal Reasons 103  Illness/Injury 104  Seek Other Employment 105  Accept New Employment 106  Job Dissatisfaction 107  Retirement 108  Transportation Problems 109  Left Area (No Spouse) 110  Left Area to Accompany Spouse 111  Leave of Absence/Sabbatical 112  Attending College 113  Position Change 114  Other (Explain Below)	200  None 201  Poor Performance 202  Position Eliminated 203  Contract Not Renewed 204  Quit in Lieu of Discharge 205  Intentionally Failing Duties 206  Violation of Rules/Laws 207  Unreasonable Tardiness 208  Provided False Information 209  On the Job Intoxication/Drug Use 210  Sleeping While on Duty 211  Insubordination 212  Abusive / Assultive Behavior 213  Destruction / Theft of Employers Property 214  Conviction of a Work Related Crime 215  Incarceration for 2+ Work Days 301  Substitute (Long Term) 302  Substiture (On Call) 303  Grant Expired 304  Part-time/Temporary Position

 

Brief Description of Separation

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