Fillable Student Asst Sep Form Edit 1-31 18 Form Ready (California State University Channel Islands)

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Student Asst Sep Form Edit 1-31 18 Form Ready (California State University Channel Islands)

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CALIFORNIA STATE UNIVERSITY CHANNEL ISLANDS
Student Assistant Separation/Clearance Form
A
COMPLETED BY DEPARTMENT OFFICE
The department designee is responsible for ensuring that the Separation/Clearance process is properly completed for each
separating employee. After completion, this form must be received by Human Resources at least 7 business days prior to
separation.
Department/Program Name:
Prepared by: Separation Chairs
Email Sent
Student Employee’s Name:
CSU Channel Islands ID #:
Last Day Physically Worked:
Class Code(s):
Employee Status:
□ Student Assistant
□ FWS Student Assistant
□ Bridge Student
□ Instructional Student Assistant
Separation Type:
□
Student Assistant Involuntary Termination
Supporting Documentation & Final Time Sheet Attached
□
Student Assistant Resignation
Resignation Letter & Final Time Sheet Attached
□
Student Assistant to Staff Position
Final Timesheet Attached
B
DEPARTMENT CERTIFICATION AND APPROVAL
Signature must be on file in Human Resources through a Signature Authority Delegation form.
Department AVP, Director, Chair or Designee Signature:
Print Name:
C
TO BE COMPLETED BY EMPLOYEE
□ Employee Unavailable to complete this form.
MAILING ADDRESS – This will change or confirm your Employment Record in Human Resource and Payroll. Your Wage and Tax
Statement (Form W-2) will be mailed to the address provided below.
Number, Street, Apt, No. City State Zip Code
Employee Signature: Date:
D
EMPLOYEE REQUIRED CLEARANCES
Department is responsible for obtaining necessary clearances from the campus Separation Chairs and submitting them to
Human Resources within 5 business days after the employee’s last day worked. Clearances should be sent in one email which
includes information received from separation chairs along with clearance dates.
Required Clearances:
Date Cleared:
University Keys/Key Cards/Keyless Entry/Locks Returned: □ Returned □ Lost
Payroll
Accounts Receivable
IT Related
(email and group shares access)
PeopleSoft Access
Pharos:
E
HUMAN RESOURCES
Human Resources Authorization: I verify that clearances are complete for the aforementioned employee.
Date:
□ Graduated
Original End Date (from req):
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Student Asst Sep Form Edit 1-31 18 Form Ready (California State University Channel Islands)

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Completed 20 July 2020

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