Exit Interview Check List

Transcription

1 Name: Exit Interview Check List Date Exit Interview Scheduled: Separatin/Retirement Date: Reasn fr Leaving (circle ne): Retirement Resignatin Terminatin Other: Health Benefits (COBRA) Life Insurance Cntinuatin Pensin (transfer, withdrawal, rllver) Vacatin Sick Time (SCOR fr nn-faculty retirement nly) State Agency Transfer (pensin transfer, sick transfer, life insurance) Unemplyment Emplyer s Frm Cnflict f Interest Frm Returning t wrk after Retirement Retrieval f Rwan University ID D yu have an Expense Credit Card, if yes was it returned? Yes Date Keys Returned t Cassidy Building Yes D yu have any ther University Prperty, if yes was it all returned? Yes Date Parking gate card returned t Parking Services Yes New Mailing Address: I certify that the abve infrmatin was discussed with me and that I (circle ne) have/will return all keys and University prperty issued t me n r befre my last day f wrk Signature: Date: 2/6/2017

2 Name: Date f Separatin: Unin Affiliatin: (circle ne) AFT CWA IFPTE PBA (Please circle ne answer fr each questin) Reasn fr leaving: Anther psitin End f Appintment Retirement Terminated Persnal n-tenure Other (specify belw): On a scale f 1 t 5, please rate the fllwing aspects f the jb by circling ne number fr each categry: 1= very dissatisfied, 2= smewhat dissatisfied, 3= satisfied, 4= very satisfied, 5= extremely satisfied Were yu satisfied with the fllwing: Immediate Supervisr Yur Psitin Wrking Cnditins Cmpensatin Training Advancement Opprtunities If under different circumstances, wuld yu have cntinued yur emplyment with Rwan University? Yes What d yu feel were sme f the advantages f wrking fr Rwan University: What if any imprvements wuld yu suggest: Interviewer s cmments: Interviewer s name (please print):

3 SCOR APPLICATION FOR SCOR DPF-279 INSTRUCTIONS: Befre cmpleting this frm, see NJAC4A:6-3.(1 thrugh 4) cncerning SCOR. 1. NAME OF EMPLOYEE (Print r Type) Lump Sum Supplemental Cmpensatin fr Earned and Unused Sick Leave fr Retirees 2. DEPARTMENT OR AGENCY 3. SIGNATURE OF EMPLOYEE 4. SOCIAL SECURITY NUMBER 5. PRESENT MAILING ADDRESS (Street, City, State, Zip Cde) 6. EMPLOYEE S TITLE AT RETIREMENT Career Senir Executive Unclassified Full Time Part Time % 7. Salary at time f retirement: 8. Effective date f Retirement: 10. DATES OF EMPLOYMENT 9. Name f Emplyee s Pensin System: PERS PFRS TPAF OTHER: PENSION NUMBER: Leaves withut pay; list dates, if any: 11. TOTAL AVERAGE ANNUAL COMPENSATION (Base salary during last 261 paid payrll days r 217 days fr 10 mnth emplyees, cunting back frm effective date f retirement). Be sure t exclude any unpaid leaves. TITLE PERIOD (Day, Mnth, Year) Number f Payrll Days X Daily Rate = Amunt 12. AVERAGE DAILY RATE DURING LAST FULL YEAR OF EMPLOYMENT: A. Fr 12-mnth emplyees divide ttal cmpensatin (Item 11) by 261. B. Fr 10-mnth emplyees divide ttal cmpensatin (Item 11) by 217. Ttal Days 261 r 217 Ttal Cmpensatin 13. UNUSED SICK LEAVE (When cnverting hurs t days, DAYS 14. AMOUNT rund ut figures t nearest quarter f day) A. Balance thru December 31, (Prir Year) (Item 13E X Item 12 B. Earned calender year t effective date f retirement divided by 2) (Emplyees earn 1.25 days per mnth) C. Ttal sick days accrued (A + B) D. Used calender year t effective date f retirement E. Balance f sick leave at retirement (C minus D) NOTE: Ttal payment NOT t exceed Sick leave infrmatin fr UNCLASSIFIED service r any perids served in unclassified service. Please attach sick leave time recrds fr last 5 years f unclassified service. A. Was there a fixed number f days an emplyee culd earn and YES NO be credited each year? Hw many? Explain hw this amunt was determined n reverse side. D. Give dates fr which sick leave recrds were maintained and are available (Indicate mnth, day, and year) F. Has this emplyee r emplyees in these class titles, received types r amunts f leave that classified emplyees did nt receive? B. Was sick leave recrded in the same manner fr all full time emplyees? If YES, what types f leave and hw much f each was YES NO E. On reemplyment, did frmer emplyee regain granted? Explain variatins frm prcedure fr classified Explain hw recrded n reverse side. sick leave utstanding at the time f separatin? emplyees. Use reverse side fr explanatins. C. Are recrds cncerning use f sick leave maintained? YES NO (If YES, were there any limitatins) YES NO (If YES, describe Explain hw maintained n reverse side. YES NO limitatins n reverse) 16. I CERTIFY that all statements n this applicatin are true and crrect t the best f my knwledge and belief under penalty f perjury. YES NO Signature f Appinting Authrity Date: 17. APPROVAL: Civil Service Cmmissin Submit cmpleted Signature Date: frm alng with pensin apprval letter t Civil Service Cmmissin Cmpensatin/SCOR Unit P.O. Bx 313 Trentn, NJ DPF-279 Revised

4 Sectin 1 tice t Emplyer INSTRUCTIONS FOR CLAIMING UNEMPLOYMENT BENEFITS YOU ARE REQUIRED, under sectin 6 (a) f the Unemplyment Cmpensatin Law f New Jersey and under Emplyment Security Rule N.J.A.C. 12: t cmplete this frm and prvide it t any wrker wh is separated (either permanently r temprarily) frm wrk fr any reasn. 1. Emplyer Name and Address: Rwan University 201 Mullica Hill Rad, Linden Hall Glassbr, NJ New Jersey Emplyer Identificatin.: Emplyer Telephne.: (856) Wrk lcatin (if different than abve): 5. Date f Separatin: 6: Separatin is: Permanent Temprary If Temprary, expected Recall Date: Sectin 2 tice t Wrker In rder t be cnsidered fr unemplyment insurance benefits, yu must file an unemplyment claim. benefits can be paid t yu fr any week befre yu actually file yur unemplyment insurance claim. Failure t file yur claim r delaying the filing culd affect yur eligibility fr benefits. Yu shuld always file yur claim as sn as pssible after becming unemplyed. Yu will nt be cnsidered eligible until yur claim is filed. When yu file the claim, be sure t have available yur Scial Security number and the cmplete, name, address, and telephne number f each emplyer that yu wrked fr in the past 18 mnths. Yu may apply fr unemplyment benefits n the Internet, 24 hurs a day, seven (7) days a week at r yu may telephne a Reemplyment Call Center. The Reemplyment Call Centers are pen during regular business hurs, Mnday thrugh Friday, excluding hlidays. Unin City Call Center (201) Freehld Call Center (732) Cumberland Call Center (856) Out-f-State Claims (888) TTY users can cntact the department thrugh New Jersey Relay: Wrkers Wh Are Unemplyed Due t a Vacatin Shutdwn: Yu shuld apply fr unemplyment benefits if yu are receiving vacatin pay in an amunt less than yur full-time wages, yu have nt refused any ffer f suitable wrk fr the vacatin perid and yu are ready and willing t wrk during the vacatin perid. *Please make certain t have this frm available when yu file yur unemplyment insurance claim. BC-10 (R-7-11) New Jersey Department f Labr and Wrkfrce Develpment Unemplyment Insurance

5 Memrandum T: Frm: Re: Terminating Emplyees Office f Human Resurces New Jersey Cnflicts f Interest Law Under the prvisins f New Jersey Statutes 52:13D-17, there are restrictins n the pst-state emplyment f terminated emplyees, when such new emplyment culd be cnstrued as cming under the Cnflict f Interest laws f the State f New Jersey. In essence, the law prvides that after terminatin frm emplyment with the State f New Jersey, n persn may appear fr r negtiate n behalf f, r agree t represent any persn r party ther than the State f New Jersey n matters which the emplyee may have cnducted investigatin n, rendered a ruling n, r given an pinin. The law prvides penalties fr willful vilatin f the Cnflict f Interest statute f a fine nt t exceed 1, r imprisnment nt t exceed sixth mnths, r bth. Under State regulatins, we are bliged t alert yu t the prvisins f this law because f yur terminatin r pending terminatin. If yu have any questins n the prvisins f this law, r desire further clarificatin, yu shuld address yur inquiry t: Executive Cmmissin n Ethical Standards 28 W. State Street Rm 1407 P.O. Bx 082 Trentn, NJ (609) Fax (609) Human Resurces Linden Hall 201 Mullica Hill Rad Glassbr, NJ fax

6 APPLICANT INFORMATION CANCEL/DECLINE/WAIVE RETIRED COVERAGE FORM State Health Benefits Prgram Schl Emplyees Health Benefits Prgram New Jersey Divisin f Pensins and Benefits Prgram PO Bx 299 Trentn, NJ HR Scial Security Number Date f Retirement (mm/dd/yy) Date f Birth (mm/dd/yy) Gender (M/F) - - Last Name Title (Jr., Sr., etc.) First Name MI PO Bx r Street Address (Include Apartment #) City State Zip Cde Area Cde Hme Telephne Number - - Status (check ne) Single Married Civil Unin (see instructins) Divrced Widwed Dmestic Partnership (see instructins) CANCEL / DECLINE ALL COVERAGE - FOR THOSE THAT DO NOT WANT COVERAGE, PERMANENTLY I am newly eligible t enrll, but I wish t decline all cverage. I understand that I will nt be permitted t enrll with the SHBP/SEHBP at a later date. I am currently enrlled and wish t cancel all cverage. I understand that I will nt be permitted t enrll with the SHBP/SEHBP at a later date. I wish t decline/cancel my SHBP/SEHBP DENTAL cverage nly. I understand that I will nt be permitted t enrll in the SHBP/SEHBP dental plans at a later date. My enrllment in medical cverage will nt be affected. WAIVE COVERAGE FOR THOSE THAT HAVE OTHER COVERAGE AND MAY WISH TO ENROLL LATER NOTE: Waiver allwed nly fr ther emplyer r spuse s emplyer cverage. Re-enrllment is nt permitted if ther cverage is private insurance (i.e.; AARP, Humana, etc.). Retirees are permitted t enrll in medical but waive dental cverage, r t enrll in dental but waive medical cverage, r t waive bth. Frmer Emplyer: I am newly eligible t enrll, but I am enrlled in anther grup plan and wish t waive cverage. In rder t enrll with the SHBP/SEHBP at a later date, I understand that I must submit a Retired Change f Status Applicatin, alng with prf f cverage lss, within 60 days f lsing the ther cverage. Check applicable bx: Medical Only Dental Only Bth * Name f Emplyer I am currently enrlled in the SHBP/SEHBP, but wish t waive cverage while enrlled in anther grup plan. In rder t re-enrll later, I understand that I must submit a Retired Change f Status Applicatin, alng with prf f cverage lss, within 60 days f lsing the ther cverage. Check applicable bx: Medical Only Dental Only Bth ** Name f Emplyer *If yu are newly eligible t enrll and wish t waive nly ne type f cverage, yu must als submit a Retired Cverage Enrllment Applicatin t enrll in the cverage f yur chice. **If yu are currently enrlled in the SHBP/SEHBP and wish t waive nly ne type f cverage, this is the nly frm yu need t submit at this time. I certify that all the infrmatin supplied n this frm is true t the best f my knwledge. Event Reasn: FOR DIVISION USE ONLY Effective Date: Lcatin.: Applicant Signature Date