EMPLOYEE SEPARATION CHECKLIST
Date:
NAME
__________________________________________
EMPLOYEE ID NUMBER
SEPARATION DATE
JOB TITLE
*Please note that the last day worked is the effective separation date*
DEPARTMENT
___________________________ ______
MANAGER
MAILING ADDRESS
____________________
CHECK ONE:
_________________________________
__________________________________
__________________________________________
___________________________ _
PHONE
__________________________________________
___________________________ _
EMAIL
__________________________________________
RESIGNING from HMC and UW System: (Complete Section 1)
LAYOFF from HMC and UW System: (Complete Section 1)
LAYOFF from HMC and UW System: (Complete Section 1
TRANSFERRING within HMC or UW System: (Complete Sections 1 and 2)
RETIRING: (Complete Sections 1 and 3)
**Managers: Please complete Section 4**
This checklist is to assist you with the separation process. Please follow the steps below and check the boxes when
each task is completed. Please return the completed checklist to
to keep in your employee
department file by
. Thank you for your service with Harborview Medical Center.
Section 1: Employee Responsibilities
Submit letter of resignation to your manager at least 2 weeks prior to your last day of work.
Send a copy to hrhmc@uw.edu or HMC Human Resources, Box 359715.
Please note: If you are transferring to another Washington State Agency, including the UW, Harborview Medical
Center or UW Medical Center systems, please add the following information to your resignation letter:

New Manager Name

Name of Washington State Agency:
HMC:
_____________________________
UWMC:
____________________________
UW:
_______________________________
Other State Agency:
____________________

Start Date in New Position
Update Employee Self-Service information at https://www.washington.edu/ess/ :
UW Directory
Update contact information from UW directory by going to Employee Self-Service and logging in
with your UWNetID and password.
Any changes to your Mailing Address and Contact Information
Please note: Your final paycheck and W-2 form will be sent to your last known address.
Update address in Employee Self Service for mailing of your final pay check and W-2 form.
[revised 07/24/14]
Page 1 of 6
You can receive assistance in completing the steps above by visiting your Human Resources Consultant at the
HMC Human Resources office in Patricia Steel Building, 401 Broadway, Suite 2100. Computer kiosks are
available for your use.
EMPLOYEE SEPARATION CHECKLIST
Go to the Benefits website at http://www.washington.edu/admin/hr/benefits to review and revise your information.
NOTE: Employees transferring directly within the UW to another benefits eligible position do not need to take any
action in regards to their benefits, unless there is a change in employee status (i.e., from classified staff to professional
staff).
Accessing retirement or Voluntary Investment Program (VIP) contributions
Continuing life insurance
Download forms appropriate to your personal benefits
If your child is enrolled in one of the University’s on-site childcare centers, you must notify the center that you are
separating from UW employment.
Review information and rates to continue medical and/or dental via COBRA
Update the following information:
Update outgoing email message through MyUW, http://myuw.washington.edu/under the “Set up Vacation/AutoReply Message” link.
Set up an auto-reply email message with notification of your separation (to set up an auto-reply message see
http://www.washington.edu/computing/faqs/html/email.autoreply or forward your account to another
employee (To forward your email account to another employee or supervisor, see
https://uwnetid.washington.edu/manage/?forward).
Standard Message should include:
- Your Separation Date
- Who to Contact for assistance and their phone number and email address
Email a test message to your manager/supervisor to ensure the auto-reply message works
properly.
Unsubscribe from email and pager group lists
Update outgoing voice mail message
Standard Message should include the following:
- Your Separation Date
- Who to Contact for assistance and their phone number and email address
Coordinate with your manager which active line to forward your voice mail to after your last working day.
Move work files/products in personal drive to centrally-shared drive
Contact the following departments:
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Page 2 of 6
You can receive assistance in completing the steps above by visiting your Human Resources Consultant at the
HMC Human Resources office in Patricia Steel Building, 401 Broadway, Suite 2100. Computer kiosks are
available for your use.
EMPLOYEE SEPARATION CHECKLIST
UPASS/Husky Card: Visit the Parking Office (8-East Hospital) to cancel deduction for UPASS and return your
card to your manager. NOTE: If transferring within the HMC system, you do not need to take any action in regards
to UPASS deductions or Staff/Husky Card.
Parking: Visit the Parking Office (8-East Hospital) to cancel and return parking permits.
If you have a Travel Card, please return and deactivate the card by contacting Department Travel Card
Administrator on or before last day of work.
Payroll: To stop your various payroll deductions refer to the website provided for contact information.
http://f2.washington.edu/fm/payroll/employees/my-paycheck/voluntary-deductions
Provide your supervisor with all department or HMC owned materials, including but not limited to:
Item Name
Item Information, ex.
ID number
Return
Date
HMC Photo ID/Name Badge
UW Staff Card (Husky Card)
HMC Parking Permit/Key Card
Keys
Locker Lock
UWATS (long distance code)
Mobile Phone
PDA
Laptop computer
Pager
Travel VISA Card
Last 4 digits:
ProCard
Last 4 digits:
Drives (Jump, Pen, Flash, etc.)
SecurID
Other:
Supervisor to
Return to:
N/A
Photo ID/Badge Office,
8EH69, BOX 359900
Parking Office, 8EH71,
BOX 359901
Parking Office, 8EH71,
BOX 359901
Photo ID/Badge Office,
8EH69, BOX 359900
Dept. manager or designate
UW Technology Center,
BOX 355675
Communications Services,
8EH-72
Communications Services,
8EH-72
Dept. manager or designate
Communications Services,
8EH-72
Travel card administrator
at Box 351117
Email cancelation to
procard@u.washington.edu
Dept. manager or designate
C&CI, Box 352830
Leave Record Summary
Review your latest summary, sign and give it to your supervisor. Keep a copy for your records.
Complete exit interview online at www.washington.edu/admin/hr/sl/hmc.
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You can receive assistance in completing the steps above by visiting your Human Resources Consultant at the
HMC Human Resources office in Patricia Steel Building, 401 Broadway, Suite 2100. Computer kiosks are
available for your use.
EMPLOYEE SEPARATION CHECKLIST
You will need your UWNetID and password. Other options: in-person or phone call with your Human Resources
Consultant at (206) 744-9220.
Sign and submit final timesheet to supervisor.
Turn in this Employee Separation Checklist to
on
Section 2: Transferring from HMC to another HMC Department or UW Department
(Complete Sections 1 & 2)
Go to the Benefits website at http://www.washington.edu/admin/hr/benefits
NOTE: Employees transferring directly within the UW to another benefits eligible position do not need to take any
action in regards to their benefits unless there is a change in employee status (i.e., from classified staff to professional
staff).
Contact the following departments:
If transfer from HMC to another HMC department, complete new request for Photo ID (blue card).
Visit HMC Photo ID Office (8-East Hospital) to update Photo ID / Name Badge with new job title and
department name.
If transfer from HMC to UW department
Visit HMC Parking Office (8-East Hospital) to stop deduction for UPASS and parking. Return Photo ID
Badge.
Forward employee’s department file to new department, if you don’t know where send the file forward to Human
Resources at BOX 359715, attention: File Coordinator and note that it’s a transfer. Human Resources will forward to the
correct department.
Section 3: Retirement from HMC / UW System (Complete Sections 1 & 3)
Note: Have you determined that you are eligible for UW Retirement?
Learn the rules and process associated with your retirement plan by contacting the Benefits Office at (206) 543-2800 or
visiting the website at http://www.washington.edu/admin/hr/benefits/retirement/index.html . You will also find information
on retiree insurance and other benefits that you can access during retirement.
Write to the Department of Retirement Systems http://www.drs.wa.gov/member/systems/pers/within six (6)
months of your projected retirement date to request an estimate of your retirement benefit and the PERS Retirement Income
Options forms. Complete and return forms to DRS.
Complete your retiree insurance forms and return to the State Health Care Authority within 30-60 days of your
retirement date
Go to the Benefits website at http://www.washington.edu/admin/hr/benefits
NOTE: You must officially retire from the HMC / UW in order to obtain all rights and benefits, and should contact
the UW Benefits Office at (206) 543-2800 or benefits@uw.edu for more information. Visit
http://www.washington.edu/admin/hr/benefits/retirement/prepare-retire/sponsors.html on rules, process, and
more information on How to Prepare to Retire.
[revised 07/24/14]
Page 4 of 6
You can receive assistance in completing the steps above by visiting your Human Resources Consultant at the
HMC Human Resources office in Patricia Steel Building, 401 Broadway, Suite 2100. Computer kiosks are
available for your use.
EMPLOYEE SEPARATION CHECKLIST
Accessing retirement or Voluntary Investment Program (VIP) contributions
Continuing life insurance
Download forms appropriate to your personal benefits
If your child is enrolled in one of the University’s on-site childcare centers, you must notify the center that
you are separating from UW employment.
Review information and rates to continue medical and/or dental via Continuing Insurance After Loss of
Eligibility (COBRA)
Section 4: Manager’s Responsibilities
Resignation letter: Copy of resignation letter received from separating/transferring employee and placed in
department file.
Submit Status Change Form to HMC Human Resources at hrhmc@uw.edu and HMC Payroll Services at
hmcpyrl@uw.edu within one business day upon receipt of resignation letter. Please contact Human Resources at (206)7449220 for form or visit the HMC Intranet: https://hmc.uwmedicine.org/BU/HR/Pages/HRForms.aspx
Forward Exit Interview link: www.washington.edu/admin/hr/sl/hmc to separating employee.
Confirm employee’s auto-reply message is active and accurate.
Verify phone line has been forwarded to another active line.
Final time sheet completed.
Obtain all HMC/UW-issued property from the employee including any UW equipment
which may be at residence. Please see Section 1: Employee Responsibilities.
Cancel/Remove Access to:
Fill out online UW Medicine Account Deactivation form at
https://info.medical.washington.edu/online/support_forms/deactivate-account.aspx
Notify credentialing office of separation (if applies) omsa@uw.edu. For more information call 206.543.1002
Forward or cancel voice mail, obtain voice mail password _
__
Cancel UWATS code. Complete form http://www.washington.edu/cac/care/phone/uwatformgl.pdf and submit
to HMC Communication Services, BOX 359-707 or fax to (206) 744-8686.
Remove access to Payroll and Online Payroll Update System (OPUS) Access/Review:
Send an email to hmcpyrl@u.washington.edu to delete the employee as a reviewer for your Payroll Unit
Code. This email should include the individual’s name, UW NetID, and PUC. Consider updating PERM
distribution list.
[revised 07/24/14]
Page 5 of 6
You can receive assistance in completing the steps above by visiting your Human Resources Consultant at the
HMC Human Resources office in Patricia Steel Building, 401 Broadway, Suite 2100. Computer kiosks are
available for your use.
EMPLOYEE SEPARATION CHECKLIST
To cancel access to OPUS, the PTR online system, and to remove individuals from the pronline mailing
list, email the following:
OPUS: mcopus@uw.edu
PTR system: hmcpyrl@uw.edu
To remove individuals from the Payroll mailing list and the Payroll Coordinator list, email
hmcpyrl@uw.edu
SecurID & Keynes: Email adminapp@uw.edu Email should include: employee name, user code,
the reason why access should be deleted, and the serial number of their SecurID card (if known). NOTE: Transferring
employees who know they will need access to SecurID in their new department can keep their SecurID card, but will
need to re-apply for access in the new department.
Remove from department systems
Send one email to separation@uw.edu to cancel/remove access to all of the following accounts/systems:
Long distance accounts, Corporate Travel Account (CTA), Records retrieval (UW Records Management Office),
Employee directory, ProCurement Cardholder or Reconciler Account, Electronic building access locking system
database, Network directories and electronic calendar (PMM, PSN, MCSOS, One-Staff, Hemingway), Travel VISA
Card, Communication Services (Cell phone service, pager, PDA.), Epic Access.
Standard message should include the following:
Employee Name
Employee Identification Number
UW Net ID
Effective Date
Note type of separation, i.e. Resignation, transfer to another department
Current Manager’s Name and Contact information
NOTE: New department is responsible for setting up access as appropriate
File completed and signed copy of Employee Separation Checklist in the Department file, completion of the Separation
Checklist ensures that the employee is closed out of the various UW systems.
Audit employee’s department file and forward to Human Resources at BOX 359715, attention: File Coordinator.
Human Resources will archive the file, for the purposes of archiving please include the file folder.
If a manager or an administrator is separating from the UWAMC: provide employee separation information to Jennifer
Uy, jauy@uw.edu in order to update the HMC ABC email.
Please sign below to acknowledge completion of all applicable sections. Please note that your last day worked is
your effective separation date.
_________________________________
Employee Signature
Date
[revised 07/24/14]
____________________________________
Manager Signature
Date
Page 6 of 6
You can receive assistance in completing the steps above by visiting your Human Resources Consultant at the
HMC Human Resources office in Patricia Steel Building, 401 Broadway, Suite 2100. Computer kiosks are
available for your use.