Change in Employment Status Checklist
To be completed by Employee's Supervisor
Employee Name ________________________________________________ Tech ID _________________
Supervisor Name _______________________________________________ Date ____________________
Type of Employment Status Change
(check one):
Retirement Effective Date ___________ Resignation/Termination Effective Date __________
Sabbatical Begin Date ________________ End Date ________________
Leave of Absence Begin Date ________________ End Date ________________
Paid Unpaid
Transfer Department/Unit Leaving ______________________________ End Date ___________
Position ___________________________________
Department/Unit Joining ______________________________ Begin Date __________
Position ___________________________________ New Supervisor ____________________________
TO BE RETURNED TO HUMAN RESOURCES WITHIN FIVE BUSINESS DAYS OF COMPLETION
A list of the possible University areas that must be notified of the change in status of an employee appears below.
Check all applicable privileges and/or materials assigned from each area and note the dates of notification and
completion. A written record of notification and confirmation is required; printed copies of e-mail messages are
preferred. Once ALL
confirmation responses have been received, sign and return the completed form with
notification and confirmation printouts to Human Resources. Click on the links below to open an e-mail message
to notify that area of a change in an employee’s status.
Date Date
Area to be notified/Privilege Notified Completed
Business Services
_______ _______
Accounts
Receivables (Fines, Parking Tickets, etc.)
Account Responsibility
ISRS/PCS Rights
ISRS/Student Payroll Rights
MAPS
Purchasing/Credit Card(s)
Consumable Inventory Rights
Cost Allocation Rights/Charge backs
Date Date
Area to be notified/Privilege
Notified Completed
Campus Card
_______ _______
ID Card
Privileges
Information Technology Services _______ _______
ISRS Access
MnSCU Security Rights
Replicated Database Rights
Data Warehouse
Long Distance Code
Voice Mail
Email and File Space
Date Date
Notified
Completed
Area to be notified/Privilege
Human Resources
_______ _______
Benefits
Employee Exit Questionnaire
ADA Equipment
Retirement
Resignations
SEMA4
Inventory Control
_______ _______
State Equipment
ADA equipment (refer to HR)
University Library
_______ _______
Materials/Equipment from Circulation
Public Safety Department
_______ _______
Parking Permit/Access
Outstanding Parking Tickets
Future Parking Privileges
Supervisor Responsibilities
How to best handle the items/areas listed below will vary,
depending on the department, as many of these are
internal to the department and will not involve other
areas of campus. The supervisor should review the list
and make sure that all items are addressed.
Department/Campus Unit
Department Lock Combinations
Department Security Codes
Employee Evaluations
Files/Documentation
--Hard copies (in file cabinets)
--Electronic copies (on computers, servers)
ID Badges
Personal Property at Workplace
Protective Equipment
Tools
Technical Support
Accounts/network privileges
Removed from distribution lists, listservs
Wipe data/recycle desktop computer
University Equipment/Hardware/Software
(including work-related items taken home)
Cell Phone Laptop Computer
Pager Software
Telephone Other??
PDA
Web Content
Campus
Department
Special Instructions/Comments:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
The above reflects an accurate accounting of access, obligations, and university resources provided to the employee.
I hereby certify that the above have been completed.
Supervisor Signature: ___________________________________________ Date: ______________
Change in Employment Status Checklist Rev 10, 10/22/19
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