Personal Email Address
Primary Work Site
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
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)
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
Interviewer Email Address
1615 Michigan Avenue
Baldwin, MI, 49304
This health center receives HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.