Department of Children’s Services



|[pic] |Tennessee Department of Children’s Services |

| |Employee Exit Process |

This questionnaire is to be completed by the SUPERVISOR to ensure State property is returned to the State of Tennessee. The SUPERVISOR will forward this questionnaire to the Human Resources Representative for processing.

ASSIGNED STATE PROPERTY AND INFORMATION SYSTEMS ACCESS

|Employee’s Name: (PRINT) |      |

|Current Position: (PRINT) |      |Last Day Worked: |     /     /      |

|Employee’s Supervisor: (PRINT) |      |

| |

|Check any of the following items/equipment the employee was issued: |

| |Issued |Returned |If Returned, to Whom/Where? |

| |Yes |No |Yes |No |Name of Person and Location |

|Keys (e.g., all doors, file | | | | |      |

|cabinets, desk, file room storage, | | | | | |

|etc.) | | | | | |

|Building Access Card | | | | |      |

|ID Card | | | | |      |

|ID Badge Number (located on back of |      |

|badge): | |

|Parking Decal/Fob | | | | |      |

|Credit Card* | | | | |      |

|Transit Card | | | | |      |

|WeCar Card | | | | |      |

|Camera | | | | |      |

|Laptop/Desktop/Tablet | | | | |      |

|Serial Number: |      |Password:       |

|Tablet Docking Station | | | | |Serial Number:       |

|Additional Peripherals (monitor, | | | | |      |

|keyboard, mouse, tablet cables, | | | | | |

|etc.) | | | | | |

|Printer | | | | |Serial Number:       |

|Pager | | | | |Serial Number:       |

|Cell Phone & Accessories | | | | |Voice Mail Password:       Access Number:       |

|Smartphone/iPad & Accessories | | | | |Voice Mail Password:       Access Number:       |

|Desk Phone Voice Mail Password | | | | |Voice Mail Password:       |

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|*Note: The employee has the option of cutting the credit card in half and returning that half with their name or turning in the |

|whole card. |

| |

|ID cards, Credit Cards, and Transit Cards must be submitted with this form. Building Access Cards and Parking |

|Decals must be returned to the employee’s Supervisor or Human Resources Representative. |

| |

|Was the employee assigned any other State Property? YES NO. If YES, describe it and indicate to whom it was returned. You may attach an additional sheet |

|if necessary. |

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|Does the employee have possession of any documents belonging to the state (forms, files, client-specific information)? |

|YES NO |

| |

|Upon any discovery that you are in possession of confidential information, you have a continuing duty to return any confidential information to the Department |

|and to not disseminate it to anyone. _____ Employee Initials |

| |

|Additional State Property: |

|      |      |

|      |      |

| |

|Termination of Systems Access: |

| |

|Termination of employee system access is executed through the submission of a “Personnel Action” email pursuant to DCS |

|Policy 7.15 and the instructions contained within the “Guidelines for Onboarding/Exiting Personnel” document. |

| |

|Personnel Action email submitted to terminate access: Yes No Employee did not have access |

| |

|Human Resources submitted Edison Security Authorization to terminate access: Yes No |

| |

|Auto Response for E-Mail Verified: Yes No |

| |

|Please encourage the employee to complete an online exit interview by following the link below: |

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|The employee and employee’s supervisor (or Human Resources office) will sign: |

| | |      | |     /     /      |

|Employee’s Signature | |Edison ID No. | |Date |

| | | | | | | |

| | |     /     /      | | | |     /     /      |

|Employee’s Supervisor’s Signature | |Date | |Supervisor/Designee’s Signature | |Date |

|*This questionnaire must be returned by the Supervisor to the appropriate Regional, Youth Development Center, or |

|Central Office Human Resources Representatives. |

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