E-mail to: “Nursing ResPLUS” and Robin Ludewig,
Gordon Landis & Travis Waldrop (contractor)
Resignation / Separation / Termination
PERSONNEL ACTION REQUEST
TO
Patient Care Resources
FROM
DATE
Employee Name:
Classification /Payroll Title:
Employee Number:
Unit /Cost Center:
NOTE: Employee must return ID, uniforms, and parking.
Please check one:
RESIGNATION
SEPARATION/TERMINATION
Effective Date:
Eligible for re-hire:
Last Day on Pay Status:
Yes
No
SEPARATION/RESIGNATION CODES: Codes AA – CL:
Codes DA – RF:
__
__
Replacement requisition?
Yes
No
Position / Classification:
Percentage of Time:
8 Hour
or 12 Hour
Number of vacancies for replacement job title:
Number of LOA’s for replacement job title:
Distribution of Last Paycheck:
Pick up by Unit Director or Employee in Annex (CHS)
Pick up at Hospital Payroll in Wilshire Center
Certified Mailed to Home
** Please note check will be mailed to the address in EDB, unless new address is
provided in grey box below.