End of Employment Form Submission — Back to Basics Behavioral Health Services

Note: this form may also be used for temporary gaps in employment.

Name of Employee:

Last Day of Work Performed on:

Please select one:

Employee Resigned (Voluntary Resignation)

Employee was Fired

General Reason for Seperation:

Background info:

Please describe the series of events leading up to the employee’s employment ending as detailed as possible:

Did the employee violate company policy?

Was the claimant made aware of the policy or unacceptable behavior that contributed to the discharge or suspension?

What is the name of the person who took the action to discharge or suspend the claimant?

If there was a prior incident:

Please explain, and what date did it happen?

If there was a prior incident:

Was the client warned for this? If so what date? Please describe the warning.

Did the employee give notice?

Yes

Date notice was given

If BHP did not give a notice please put N/A

What date did the employee provide as an intended last day of work?

If BHP did not give a notice please put N/A

Did the employee work out their notice?

If BHP did not give a notice please put N/A

Yes

N/A

Are there any other documents that support? If so, list them below:

Would you Rehire? (If No, Please explain)

Form Completed by:

Date Form Completed:

mm/dd/yyyy