SHP-FACULTY / STAFF SEPARATION CHECKLIST
Name: ___________________________________________________ Faculty Staff
Department: _______________________________________________ Date of Separation:________
Supervisor: ____________________________
Please respond to each item on the Checklist. If response is “No”, attach explanation.
The completed form should be returned to the office of Faculty Affairs & Personnel Administration
If faculty leaving is a Program Director, Director or Chair:
FACULTY & STAFF | |||||
No | Yes | N/A | To whom? | Date | |
Swipe card access & Key box code deactivated | |||||
ID returned/Parking hangtag returned (FAPA) | |||||
Suite/office/desk keys returned (Facilities) | |||||
Lab/clinic coats returned (Dept.) | |||||
Cell phone returned (Facilities) | |||||
Laptop/desk top printer/computer equipment returned (IT) | |||||
Telephone line(s) service deactivated (Facilities) | |||||
Confirmation of deactivated e-mail, computer privileges*(FAPA) | |||||
Course materials provided to department (FACULTY) (Dept.) | |||||
Submission of Final Time and Effort Report (FACULTY) (Dept.) | |||||
Other:_____________________________ | |||||
CLINICAL FACULTY | |||||
Clinical privileges terminated | |||||
Patients completed or transferred | |||||
Patient records completed | |||||
Financial accounts settled | |||||
Clinical equipment returned | |||||
Other: _____________________________ | |||||
RESEARCH FACULTY | |||||
Grants closed or transferred | |||||
IRB protocols closed or transferred | |||||
Animal protocols closed or transferred | |||||
Laboratory equipment returned | |||||
Agreement to Remove Research Data signed | |||||
OTHER SCHOOL-RELATED ITEMS | |||||
Data Files Transferred | |||||
Research Labs decommissioned by EOHSS | |||||
Copier code deactivated (if applicable) | |||||
Removal from Dept. mailing lists | |||||
Tuition Reimbursement issues satisfied (FAPA) | |||||
Banner/PeopleSoft Access Terminated (Finance Office) | |||||
SHP IST to confirm CORE/Email access Terminated (SHP IST) | |||||
FAPA TO SEND NOTIFICATIONS | |||||
If faculty leaving is a Program Director, Director or Chair: | |||||
Notify Enrollment Services, Associate and Assistant Deans | |||||
If faculty leaving is currently serving on any Rutgers or SHRP committee(s): | |||||
List committee(s) on back; notify each committee of the separation |
Signature of Department Chair or Supervisor:______________ Date__________________
*School should send a test email to confirm that the address is undeliverable; therefore inactive.