SEPARATION CLEARANCE FORM - University of Cincinnati

SEPARATION CLEARANCE FORM(TO BE INITIATED BY THE ADMINSTRATIVE UNIT)Name:Last Name First Name M.I.Department:Job Title:UCID (M#): Full-Time Part-TimeForwarding Address:Street City State ZipToday’s Date: Last Day Worked: Separation Date:DEPARTMENT PROPERTY Applicable Not ApplicableComputer Equipment (laptop, thumb drive, etc.)Tools, Equipment, Job AccessoriesDepartmental Keys (desk, files, vehicles, locker, etc.)UniformsPagers/Communication DevicesPurchasing/Campus Services/Bearcat CardsLab EquipmentOther: (intellectual property)Authorized SignatureJob TitleDatePUBLIC SAFETY Applicable Not ApplicablePhoto I.D. BadgeUniversity Bldg/Door KeysOther:Authorized SignatureJob TitleDatePARKING Applicable Not ApplicableParking Decal/Key CardParking PermitOther:Authorized SignatureJob TitleDateI certify the information I have furnished on this form is true, correct, and complete to the best of my knowledge.Furthermore, I understand the information I supplied may be audited by the University or its representatives.Employee Signature:HRSC Signature:Revised 08.26.09 SBDate:Date:

SEPARATION CLEARANCE FORM(TO BE INITIATED BY THE ADMINSTRATIVE UNIT)INSTRUCTIONS FOR SEPARATION CLEARANCE FORMAll University of Cincinnati employees are required to complete a separation process whenseparating employment. To receive allowable compensation of unused accrued vacation andsick time in the pay period following issuance of the final regular paycheck, employeesseparating from the University are required to complete the separation process. This includesreturning all University property to the appropriate university department or office locationsand paying outstanding fees and financial obligations. Failure to complete the separationprocess will affect the timing of the receipt of allowable compensation in the final paycheck.The process includes the following steps:1. The administrative unit initiates the Separation Clearance Form.2. The employee must return University property to the appropriate location and have the SeparationClearance Form signed at each location.Public SafetyUptown Campus 513-556-4925Regional Campuseso Raymond Walters 513-936-1520o Clermont 513-732-5240Parking ServicesUptown Campus 513-556-2283Regional Campuseso Raymond Walters 513-936-1520o Clermont 513-732-52404 Edwards Building123 Muntz Hall145 Student Services Building4 Edwards Building123 Muntz Hall145 Student Services Building3. The employee must schedule an exit interview with the Human Resources Service Center (HRSC)(513-556-6381) located in Room 340 University Hall prior to the last day of work. The completedclearance form should be presented to the HRSC at the exit interview.4. At the exit interview, the employee must meet with an HRSC representative to review benefitcoverages. Eligible employees will receive a letter in the mail following the processing of theirtermination explaining COBRA continuation of coverage, premium rates, and when payments willbe due. The HRSC will review any delinquent obligations the employee might owe the University.Note: The employee should provide a forwarding address by contacting the HRSC if the addresslisted on the front of this form changes to ensure you receive your W-2 form timely.Human Resources Service Center (HRSC)All Uptown Units and Regional Campuses PH: 513-556-6381Fax: 513-556-4501Room 340 University Hall51 Goodman Drive, ML 0039Cincinnati, OH 45221-0039Revised 08.26.09 SB