Sample- Termination, Non-Renewal, Reduction in Force Data Form

Confidential Internal Use Only

Date:

Dear Parish and Schools & Human Resources,

(Parish/School name) is requesting a consultation on a proposal for:

Termination of Employment

Non-renewal of Employment

Reduction in Force

Job Abandonment (Voluntary Termination)

Employee Information:

Name: Hire Date: Job Title:

Status: Exempt Non-Exempt Part-Time Full Time Contracted Non-Contracted

Past documented discipline or corrective action including dates (please attach copies):

Verbal Warning:

Written Warning:

Suspension:

Performance Improvement Plan:

Demographics: Gender , Age , Race

Has the employee had any of the following during their employment (YES or NO):

Leave of absence (FMLA, personal, etc.)

Requests for accommodations such as physical workspace/environment, etc.

Made a complaint of unfair treatment or harassment

Filed a workers compensation claim

Other Potential Risk Factors:

Further Details:

Sincerely,

Name: Title:

School/Parish:

Contact Information:

Phone #: Email:

Please let me know if you have any questions or requests for additional information.