California State University, Fresno
Office of Faculty Affairs
Separation Notice
For Faculty Affairs Use Only: Rev. 11/2016 APS:Forms\Separation
PS Checklist: _____________ Job: ____________
Access Updated: _____________ To PR: ____________
Use this form when: A temporary faculty member, Teaching Associate, Graduate Assistant, or Instructional Student
Assistant was approved (given an appointment notice) during a set period of time and the individual has decided to resign,
quit, terminate, or retire either before, during the appointment or at the end of the scheduled appointment. Do not use this
form for tenured, tenure track, or FERP faculty or when the temporary faculty member or student should be requesting a
medical or personal leave of absence.
Directions:
1) Complete the form.
2) Attach documentation from the individual stating reason for separation.
3) Department Chair reviews, signs and dates; then begins separation process to collect technology, etc.
4) Dean reviews, signs and dates; then determines if Substitute or Late Start appointments are needed.
5) Forms should be submitted to Faculty Affairs prior to or same date as separation notice for processing.
6) Review Payroll Certification to ensure proper payment associated with the separation.
__________________ ________________________________________________________
Employee ID Name (First Last)
__________________ ________________________________________________________
Dept ID (5 Digit) Department Name
Appointment Dates (Dates on the current appointment notice/letter/offer):
Beginning: ____________________ Ending: ___________________
Last Day Worked (last day on Payroll): ______________ Date Notified of Separation: __________
Notes (e.g., cancelled appointment notice): _____________________________________________
___________________________________________________________________________
___________________________________________________________________________
Attached is the documentation confirming this separation/resignation; and I have reviewed the information and
understand that the individual will be removed from Payroll as of the Last Day Worked indicated above. I
have/will begin collecting any department and/or college issued inventory. I will ensure that the Payroll
Certification form is reviewed to avoid overpayment which could result due to separation.
Department Chair: ____________________________________ _________________
Signature Date
Dean: _______________________________________________ __________________
Signature Date
