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.