LEAVERS’ FORM
To be completed by line manager
Guidance notes can be found using the following link:
http://www.keele.ac.uk/hr/policiesproceduresandguidance/
1) Employee Details
Name:
Leaving date (last day of employment):
School/Department:
Forwarding address:
Job Title:
2) Reason for leaving
Resignation*
Retirement*
Dismissal
Other (please specify)
*A copy of the notice of retirement or
resignation must be attached to this form
(unless already forwarded to HR).
3) Activity and Location on Leaving (This is a
HESA requirement, please tick appropriate boxes)
Activity
Working in a higher education institution
Working in another education institution
Working in a research institute (private)
Working in a research institute (public)
NHS/General medical/general dental practice in UK
Working in another public sector organisation
Working in the voluntary sector
Working in the private sector
Self-employed
Registered as a student
Retired
Not in regular employment
Not known
Location
England
Wales
Scotland
Northern Ireland
UK (not otherwise specified)
Other EU
Non-EU
Not known
Information refused
4) Annual Leave
It is an expectation that the employee would have taken their pro-rated annual leave entitlement before
the leaving date. In the exceptional circumstances that an employee has been unable to take all of their
accrued annual leave, please state the number of days/hours to be paid and reason why:Hours / days owed –
Reason -
5) Is this member of staff employed under a certificate of sponsorship
YES NO ( please delete as applicable)
6) Recovery of monies owed to the University
If you are aware of any monies the employee may owe the University please specify here. (Examples
may include relocated expenses, maternity/paternity/adoption pay and annual leave – please refer to
the guidance notes for more information).
7) Recovery of University property - This is a prompt to recover any University property from the
employee prior to leaving
Keele Card
Keys
Uniform
Car Park Permit
Research Passport ID Cards
8) To be completed by Line Manager
Laptop
Mobile Phone
Badge
Name: …………………………………. Signed: ……………………………………… Date: ……….…………
To be completed and returned to the Human Resources Department
SG 8/1/13