Termination Request Form

TERMINATION REQUEST FORM (Involuntary)
Please utilize this form to request terminations. It is super critical for the HR department to know of all terminations to help manage risk. We need to ensure we have all the accurate information (including FACTS: what was said, heard and observed directly).
- standardized approach
- one platform to track termination requests
- ensure we have the necessary documentation
Along with ensuring we have the information to terminate this information will be helpful for unemployment claims.

Submitting this form will go to your HR Generalist & Regional Manager for review and ensure termination notice is provided in a timely manner within same day.

Should there be issues or concerns based on review, the HR Generalist will review with you and RM.

IF this is a serious matter, this form does NOT replace the need to pick up phone and call Regional Manager and HR Generalist.
Office Location
State*
Office Location*
Director*
Regional Manager*
Manager requesting termination

First NameLast Name
Name of Employee terming

First NameLast Name
Hire Date of Employee

MonthDayYear
Date
Position*
Is employee within probationary period (less than 90 days from hire date)
Prior disciplines or corrective actions?

verbal conversationdocumented email recapverbal warning/corrective actionwritten warningPIP (Performance Improvement Plan)Other
Reason to terminate

Violation of Work RulesViolation of Code of ConductPerformanceAttendanceMis-alignment of Core ValuesClinical: Quality of Work/NegligentPatient CareOther
Has Employee cited anything related to:

HarassmentDiscrimination (Race, Age, Gender)ADA (Americans Disability Act)/Medical IssuesRetaliationBullyingHostile Work EnvironmentAbuse of Authority/Power
Description of events leading to terminate employment?
Review of prior corrective action attempts (Including coaching, progressive discipline, etc.). Please provide progressive discipline steps and dates. Example: 2/15/24: Verbal conversation of attendance. Timeline/Summary
Extenuating circumstances and/or other relevant information (if applicable)
Priority level to terminate:

High priority (needed immediately, impacting patients/teams and quality issues)Other priority (need further guidance)
Please upload any additional information (Prior documentation, etc.)

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TERMINATION REQUEST FORM (Involuntary)