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:

Signature of Department Chair or Supervisor:______________                                        Date__________________

*School should send a test email to confirm that the address is undeliverable; therefore inactive.