Employee's Name:

TERMINATION REPORT

_

Department: 	_
Social Security Number:			 	  

Termination Effective Date:  	_ Clock Number:	     

Type of Separation (Check one):

 	     Resignation (Attach letter of resignation)	 	
      	     Mutual Agreement							                          		              

Dismissal
Other:				

Reason for Separation:

 	  Absenteeism/Lateness
 	  Family
 	  Reduction in Force
Other:				

 	  Changing Job
 	  Incompetence

Employee Evaluation (Check appropriate rating):

Attendance	_	Unsatisfactory	         Fair	_ Satisfactory	        Good	 _ Excellent	
Cooperation	_	Unsatisfactory	         Fair	_ Satisfactory	        Good	 _ Excellent	
Initiative	_	Unsatisfactory	        Fair	_ Satisfactory	        Good	 _ Excellent	
Job Knowledge	_	Unsatisfactory	        Fair	_ Satisfactory	        Good	 _ Excellent	
Quality of Work	_	Unsatisfactory	        Fair	_ Satisfactory	        Good	 _ Excellent	

Recommendation: 	 	  Without Reservation
 	  With Some Reservation
 	  Would Not Recommend

Rehire?	 	 Yes 	 	 No

Additional Comments:																																																						
Signed:  	_	Date:					
Supervisor's Signature

FOR OFFICE USE ONLY

Benefits Cancelled:			 
Life:		Medical: 			 Other: 				
Employee informed of benefit continuation rights: 			(indicate date notice sent)
Personnel  Approval:						         Date:				
Northeastern Retail Lumber Association 12-11