Employee Name
Personal Email Address
Primary Work Site
Position
Effective Date
Has your address or phone number changed? No ChangesAddress ChangePhone Number ChangePhone Number & Address Change If yes, what are they?
Keys to the building/swipe card returned
Resignation Statement
Credit Cards
What should be done with PTO?
ID Badge Returned
Equipment Returned (laptop, wireless mouse, cell phone, internet card, Etc.)
Laptop Tag Number
Logins (What did you have logins for? Email, Champs, NextGen)
Handbook
Other items obtained
To be discussed Extended medical coverage insurance plan (for COBRA requirements)Outstanding Bills to PCUnemployment Insurance Claim (provide instructionsheet)PTO payout if applicableFHC Debt
Other notes to be shared
Bamboo offboarding tasks have been assigned YesNo
Interviewer
Interviewer Email Address
