The University of Texas Houston
Health Science Center
DENTAL BRANCH
TERMINATION CHECK-OUT SHEET
| Name: _______________________________________ | *Termination Date: _______________________ |
| Department: __________________________________ | Termination Reason: ( ) Separation ( ) Retirement |
| Employee: Before a final salary warrant is issued, you must obtain proper signatures indicating return of items issued to you as indicated below. |
| Department: (a) Employee must sign a completed signed Payroll Time Sheet. (b) Prepare and submit a Personnel Action Request Form to ensure completion of the termination check-out procedure. |
Signatures Required
Item Description |
Accepted By |
Initials |
Date |
|
| Departmental | Equipment; Departmental Supplies; UT Credit Card | Supervisor and/or Department Head | ||
| Uniforms / Lab Coats(if applicable) | Supervisor and/or Department Head | |||
| Departmental / Environmental Health and Safety | Laboratory walk-thru with EHS Representative (phone for appointment 500-4193) | Room 300S | ||
| Library | Library Book(s); Card | Room 133 | ||
| Dean’s Office | Keys | Room 147 | ||
| Parking (if applicable) (Notification sent to TMC Parking Services) |
Room 163 | |||
| Identification Badge | Room 163 | |||
| Payroll Time Sheet | Room 163 | |||
| Personnel Action Request Received | Room 163 |
*Termination Date is the last day an employee works (not the first day the employee does not work).