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Termination Report
Termination Report
"
*
" indicates required fields
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Employee Name
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First
Last
Location Worked
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Choose location
B1 - 328 North Avenue, Burlington
B2 - 103 Shelburne Road, Burlington
B35 - 793 Shelburne Road, South Burlington
B4 - 219 Main Street, Burlington
B5 - 1118 Williston Road, South Burlington
B6 - 315 Shelburne Road, South Burlington
B8 - 1800 Williston Road, South Burlington
B9 - 801 Williston Road, South Burlington
BE1 - 15 South Main Street, Barre
BE2 - 169 Washington Street, Barre
BE4 - 475 North Main Street, Barre
BTH - 137 Main Street, Bethel
BRN - 1 Grove Street, Brandon
BRS - 3 West Street, Bristol
C1 - 156 Roosevelt Highway, Colchester
C2 - 3570 Roosevelt Highway, Colchester
DB - 3923 US RT 5, Derby
EB - 127 Main Street, Enosburg
ES1 - 56 Pearl Street, Essex
ES2 - 25 Jericho Road, Essex
FL - 51 Lake Morey Road, Fairlee
LB - 114 Hanover Street, Lebanon
MB - 25 Court Street, Middlebury
MLT - 371 Route 7, Milton
M1 - 5 Memorial Drive, Montpelier
M3 - 108 State Street, Montpelier
NF - 73 North Main Street, Northfield
PF - 3705 US Route 7, Pittsford
RD - 16 North Main Street, Randolph
STJ - 490 Railroad Street, St. Johnsbury
SW1 - 188 First Street, Swanton
SW2 - 2 Canada Street, Swanton
VG - 65 Main Street, Vergennes
WF - 5127 Main Street, Waitsfield
WB1 - 1 North Main Street, Waterbury
WB2 - 713 Waterbury Stowe Road, Waterbury
WN1 - 155 Main Street, Winooski
WN2 - 280 East Allen Street, Winooski
Office - 32 San Remo Drive, South Burlington
C-Store Contracting
Pick the store the employee was assigned
Employee Job Title
*
Choose one
Store Clerk
Stocker
Assistant or Deli Manager
Store Manager
General Maintenance or Construction
Office employee
Other
Last Day Worked
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Termination Date
*
Are the termination date and last date worked the same?
*
Yes
No
Why was there a delay in the termination date from when the person last worked?
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Type of Separation
*
Choose one
Quit / Resignation
Dismissal
Quit for Medical Reason
Other Reason for Separation
Quit/Resignation: What reason did employee give for quitting?
*
Choose One
Moving
Changing Jobs
Job abandonment
Health
Family or domestic issues
Conflict with supervisor or coworker
Work Conditions
Payment issues
Other
Please note any actions or comments by employee indicating intent to quit. In other words, how did you KNOW the employee quit?
*
Was there an incident that lead up to this?
*
Yes
No
Describe the incident that lead up the quit:
*
Did the employee give notice?
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Yes
No
How much notice did the employee give?
*
Describe any contact with the employee regarding this matter, including any attempts to contact them
*
Include details such as date, and mode of communication... text, written note, phone call, etc.
Who terminated this employee
*
First
Last
Reason for Dismissal
*
Absenteeism / Lateness
Theft
Violation of company policy
Workplace violence
Failure to meet work expectations
Other
List the reason for dismissal
*
List the most recent days when employee was late or missed a schedule shift:
*
What company policies did employee violate?
*
Select all reasons why employee's job performance was unsatisfactory:
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Not completing assigned tasks
Negative attitude impacting work environment
Disruptive behabior impacting work environment
Failing to comply with policies & procedures
Failing to comply with safety standards
Insubordination: Disrespectful/rude to management
Other
List why employee's job performance was unsatisfactory:
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Date of Final Incident
*
Describe the final incident resulting in the dismissal of the employee
*
What reason(s) were given to the employee about why they were being terminated:
*
Warnings Given
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Verbal
Written
None
Verbal Warnings: List Date of Warning; Who gave it; and Work issue(s) it was given for
*
Written Warnings: List Date of Warning; Who gave it; and Work issue(s) it was given for. Attach below if not turned into office yet
*
When was employee warned they could lose their job?
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When did the behavior continue after the last warning?
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What reason did employee give for repeating the behavior?
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When did the theft occur?
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Type of Theft (check all that apply)
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Theft of Money
Theft of merchandise/product
Unauthorized discounts and/or returns
Theft of property
Theft of Hours
Other theft
Did the employee admit the theft?
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Yes
No
What occured?
*
Describe what the employee was accused of:
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Were there any witnesses?
*
Yes
No
Was the employee shown any photos or video of the theft?
*
Yes
No
Was the employee questioned by police?
*
Yes
No
Did employee give a written statement?
*
Yes
No
Other Reason for Separation
*
Example: did not return from leave
How was employee notified that they were being discharged?
*
In person
Telephone
Text message
Email
Other
Employee
Turned in keys
Turned in uniform
Is this employee rehireable?
*
Choose one
Yes, without reservation
Yes, with some reservation
No
Manager Name
*
First
Last
File
Max. file size: 50 MB.
Signature
*
Your Name
Your Name
Your Name
Your Name
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