Department of Medicine
Employee Departure Checklist
DA/Supervisor/PI—(1) Please visit http://term.medicine.wisc.edu/ and submit a “New Departure Request” for the
employee; (2) If applicable, email the resignation letter to DOM HR (hr@medicine.wisc.edu) and your Division
Administrator immediately after you receive it from the employee; and (3) Review Section II of this checklist and
ensure that all applicable items are completed.
Note: You do not need to send completed checklist to HR, but please retain with your files.
Section I:
Employee Name:
Forwarding
Contact Info:
Last Day of Work:
Division:
Last Day on Payroll:
Supervisor:
Is employee’s next employment with UW System or
State of WI? If so, where?
Reason for departure (e.g. resignation, retirement,
terminal position, dismissal):
Section II - Division Administrator / Supervisor Responsibilities:
Badge/IDs (building access)—ensure UW Health photo ID badges are turned in to you; UWHC photo ID badges
should be hand delivered to UWHC Security staff (E6/206) for deactivation and disposal
Cell phone & accessories—ensure turned in if DOM owned; disregard if personally owned and reimbursed
Clinical paperwork—ensure all clinical-related paperwork needing signatures is complete
Computer equipment:
If University owned: Ensure DOM computer equipment ordered and supported by the Helpdesk is returned.
This equipment is identified by stickers with the Wisconsin shield and assigned a number such as DOM1234.
Faculty and staff are not authorized to trade in or dispose of any university property without prior purchasing
services approval. For more information--see UW-MSN policy http://www.bussvc.wisc.edu/purch/ppp18.html or
http://www.rsp.wisc.edu/awardmgt/nihtransfer.html.
All portable devices must be reviewed by departmental IT staff for disposal or removal of data when no longer used
for business purposes. http://hipaa.med.wisc.edu/securitypolicies/PortableDevices.pdf
UWMF professional allowance: Any information technology equipment less than 1 year old purchased by faculty
and reimbursed with UWMF professional allowance funding must be returned to the department upon departure.
This includes, but is not limited to: iPads, laptops, PDA's, desktops, etc… See UWMF Professional
Expense Policy--http://www.medicine.wisc.edu/accounting/uwmfprofessionalexpense
Data transfers for individual data directories—contact the Helpdesk for assistance. Data files for the terminated
account can be transferred to a working unit (i.e. another person in the operational area). The user’s supervisor or
the unit’s administrator must contact the Helpdesk with the request. Data will be available for up to six (6) months
after the termination date for this purpose; after this six-month period, data is purged and is no longer recoverable.
Can faculty or staff take research (University data) with them?
If a researcher or faculty member of DOM is the data custodian of a database that was developed for general,
unspecified research and contains “full” PHI, a limited data set of the research database can be taken from UWMadison with a data use agreement. Consult with campus HIPAA privacy officer.
If a researcher is the data custodian of a database that was developed specifically for an IRB approved protocol
that is still open, the researcher should consult with the IRB whether or not the database can be taken with the
researcher and under what conditions.
Effort Certification—notify DOM Effort Coordinator (Betty Weiss) that employee has left and whom to reassign
card to.
Email—remind departing employee to set out-of-office message. The Helpdesk can not grant access to another
employee’s email/calendar without the consent/approval of the owner. The owner is encouraged to grant access.
Only the dept. chair or administrator can grant access to a user’s email/calendar without his/her approval/consent.
Exit interview—offer in-person exit interview (with HR, Division Head, or DA); IF in-person exit interview is
declined, print or send link to written form (http://www.medicine.wisc.edu/sites/default/files/exit_interview.pdf) and
encourage employee to complete/send in to DOM HR. Written form may be submitted anonymously.
Expense Reports—submit and have all expense reports approved before end date to ensure reimbursement
Grant/research—ensure transfer, closeout and signatures
Keys and/or key cards—ensure turned in to you or other appropriate person (in an envelope with names and
keys clearly identified)
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Lab coat—ensure turned in
Leave payouts—contact payroll if leave payout is to be paid from different account than usual salary
List serves—if you are a list serve moderator, terminate off list serve
Locker/desk—ensure lock is removed and personal items are removed from lockers/desks
Pager—ensure turned in
Payroll—contact to confirm leave balances/funding for payouts; address outstanding leave statements
Purchasing card—card must be returned to MARK MCCLINTOCK (4150 HSLC), cut up with a note requesting the
card be canceled
Replacement plan—list of outstanding issues, plan for effective continuation of departing employee’s duties;
transition plan for computer/email; contact HR if necessary to begin recruitment process for a replacement; etc.
Retirement—please see the following link for emeritus/emerita information for unclassified staff:
http://www.ohr.wisc.edu/polproced/UPPP/2001.htm University staff retirement information may be found at this
link: http://www.ohr.wisc.edu/polproced/CPPP/cppp_chapter20.pdf Retirement certificates may be ordered by
using the following link: http://www.ohr.wisc.edu/retirement_certificate.htm
Safety equipment—ensure DOM equipment is returned (note: we are not authorized to trade in or dispose of any
property without prior purchasing services approval for more information see UW-MSN policy
(http://www.bussvc.wisc.edu/purch/ppp18.html or http://www.rsp.wisc.edu/awardmgt/nihtransfer.html)
Signage—ensure turned in or removed
Student Hourly Payroll—if employee is authorized to approve time for students, contact Payroll to remove
authorization and designate a new approver/backup.
Timesheet/Leave Accounting—review, sign and submit to payroll or submit electronically (including all leave
accounting/timesheets through last date paid)
UWMF appointments—also complete UWMF Departing Provider Checklist (on UConnect, requires sign-on)
Voice mail—get personal code so you can easily reassign
Faculty Only:
Retirement: Emeritus status requires DOM vote; Contact DOM HR (Amy Pritchard) for more information.
Disseminate DOM/Divisional Faculty Compensation Policy to Clinical Faculty— Per UW Health Policy on
Compensation upon Voluntary Termination within 30 days of receipt of resignation notice, clinical faculty must be
sent “Department’s written policy or other formal documentation of the Department’s termination process, its
compensation process of separating clinical faculty physicians, its projections for clinical and other productivity
during the 90 day term of notice and requirements of participation in the year end true up process”. A template of
this letter can be found on our website at:
http://www.medicine.wisc.edu/sites/default/files/CompensationUponVoluntaryTerminatio%20Policy%20.pdf
Outside offers form—http://www.medicine.wisc.edu/sites/default/files/OutsideOffers_form_F0841_1.pdf; complete
and send to DOM HR (Amy Pritchard).
Section III - Information Systems Department Responsibilities:
Remove from web page, directories
Disable user access---per DOM Termination of User Access policy http://www.medicine.wisc.edu/infosys/policies
Bounce back message: Employees should consult with their supervisor to create a bounce back message in the
email system on their last day of employment. DOM Helpdesk can setup the bounce back message if the
employee’s termination date has passed. Supervisor can send message text to help@medicine.wisc.edu.
Section IV - Human Resources/Payroll Department Responsibilities:
CHECK HR PROXY DAILY FOR TERMINATION NOTIFICATIONS
Resignation Acceptance: send resignation & draft acceptance letter to Kathy/Madelyn immediately
upon receipt. Send signed acceptance letter to employee & save copy for P-file.
SMPH notification: Submit job change request in JEMS; email copies of resignation/dismissal letter
and signed resignation acceptance letter (if applicable) to SMPH HR; save copy for P-file
Payroll: copy DOM payroll on SMPH notification email or give letter to payroll -- Payroll checks for
outstanding leave issues and coordinates leave payout request through SMPH if needed.
End Employment Notification: Review and finalize Departure Request using Terminations App
(http://term.medicine.wisc.edu/); print copy of End Employment Notification email for file.
Employee departure information sheet: email to departing employee
Exit interview: email written form and invitation for in-person exit interview to employee; DOM HR
Mgr will complete in-person interview if requested & maintain file of completed interviews
Health Link: Delete employee from Health Link spreadsheet
I-9: pull from active file; mark start date/end date/destruction date on I-9 AND in GIS system if
employee has electronic I-9 on file and is leaving UW-Madison employment; file alphabetically by
destruction year [must save I-9 for later of 3 yrs after start date or 1 year after term date]
Organizational chart: update org chart (mark future end date in red or delete if already termed)
WebHR: add end date/reason when letter received; move to inactive after last day on payroll
Personnel file: file resignation letter and all ending paperwork in P-file
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Date
Faculty Only: (Amy P. completes items below)
Faculty termination and outside offers table—update; route copy of term letter to UWMF-Mickie/Jeff (AP)
Provider Enrollment Update or Termination Form—Amy Pritchard completes for DOM; link may be found at
http://www.uwhealth.wisc.edu/uconnect/hr/uwmf_endappt.asp; Note--this is also listed on the UWMF Departing
Provider Checklist as a task for the Clinic Manager/Department (Division) Administrator
UWHC appointment change form—Amy Pritchard completes for DOM; form requires Chair’s signature, then
needs to be routed to the UWHC Medical Staff Affairs Office
UWMF on-line provider termination form—Amy Pritchard completes for DOM and submits to UWMF, link:
https://uconnect.wisc.edu/depts/uwmf/provider-enrollment/
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Rev. 11/18/15