7.01b Separation Checklist - Exhibit

Document Type:      Exhibit
Number:                  7.01b
Effective:                 05-01-06
Revised:                  06-10-21
Legal References:     I.C. §§ 45-606


To Be Completed By Supervisor and sent to Human Resources

EMPLOYEE NAME: __________

EMPLOYEE ID #: __________


DEPARTMENT: __________

When an employee separates from employment, the employee’s supervisor is responsible for completing this check list within 48 hours of the employee’s last day and sending it to Human Resources for inclusion in the employee’s official personnel file.

1. After receiving an employee’s notice of separation, complete a Personnel Action Form (PAF) and forward this checklist to HR.
2. Encourage the employee to complete an exit survey.
3. Ensure that all city property is returned prior to the last day of employment.
4. Ensure the employee’s hours worked and leave time was accurately recorded in the city’s timekeeping system.
5. If the employee participated in the city’s tuition reimbursement program, you must promptly notify the city’s tuition reimbursement administrator of the separation to ensure any money owed to the city by the employee is refunded.
6. Ensure the employee submitted the appropriate requests for reimbursement for any money they were owed for mileage, phone stipend, etc. If permissible, it can be considered for inclusion to the employee’s final pay.
7. If the employee was receiving any utilities paid for by the city, ensure the utilities are terminated prior to the employee’s last day.

Verify the employee’s personal mobile device, tablet, thumb drives, etc. are cleaned of city information.


The supervisor is responsible for collecting all city and department property before or at the time of separation, including but not limited to the following items. Please specify each item and note the date it was returned. Write N/A for items not issued to the employee.

City P-card or gas cardDate returned:__________
City/department ID badge(s)Date returned:__________
Employee SIDA badge (Airport only)Date returned:__________
Laptop/Surface/Docking Station, etc.Date returned:__________
Monitors, webcam, speakers, headsetDate returned:__________
Thumb drives, work products, etc.Date returned:__________
Mobile phone and/or pagerDate returned:__________
Keys to building, desk, file cabinetsDate returned:__________
Tools or suppliesDate returned:__________
Parking permitDate returned:__________
Citrix key fobDate returned:__________

Please list any city property in the employee’s possession that was NOT returned:

Once you have completed this checklist please print and sign your name and submit to Human Resources for inclusion in the employee personnel file.

Supervisor’s Printed Name: __________

Supervisor’s Signature: __________

Date completed: __________

CC: Employee Personnel File

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