HTML Preview Termination Exit Interview Form page number 1.
Exit Interview Form/Notification of Termination
Name of Employee: ________________________
Date of exit interview: ______________________
Employee Supervisor: ______________________
Please be advised that (Name) _____________________________, Employee # _________, has
terminated employment with the Town of Berlin for the following reasons(s);
___ Quit, reason unknown
___ Quit, starting employment elsewhere
___ Discharged for Misconduct
___ Failed to meet performance standards
___ Lack of Work
___ Employee is retiring
___ Other: _________________________________________
Do you expect to recall this employee? ___ Yes ___ No
___ Employee is no longer considered an employee of the Town of Berlin for any reason (not
eligible to return at all).
___ Employee is no longer a permanent employee but may return from time to time as part-time
employee in my department.
___ Employee is no longer employed in our department, but remains working as a town
employee in the following capacity:
___ On-Call Patrolman or Dispatcher
___ Law Enforcement – Details/Special Duty
___ Election Worker
___ Highway – On-call snow plowing/tree removal/storm damage
___ Call Firefighter
___ EMT/First Responder
___ Substitute Teacher
___ Other: __________________________
Effective Date of Termination/Retirement: ___/___/____
Has employee been advised of COBRA rights if applicable? ___ Yes ___No ___N/A
Items to be returned (where applicable): employee to date and initial:
___ Keys ___ Computer Equipment
___ Blackberrry ___ Town Phone
Other items: __________________________________________
Signature of Former Town Employee: ________________________ Date:_____________
Signature of Supervisor: ___________________________________ Date:______________
Copy provided to Personnel Committee (date): __________
Copy provided to Town Treasurer (date): __________