HR Leavers Checklist Form HR – Leavers Form Name of Leaver(Required) First Last Department/Parish(Required)Leaving Date(Required) DD slash MM slash YYYY Human ResourcesThis form must be completed by the line manager and submitted by the payroll deadline in the current month/as soon as the employee has left the DioceseEmployee Number (if known)Total annual leave taken (days / hours)Holiday entitlement is calculated in hours for part-time employees, days for full time employee. Please specify which appliesDaysHoursHas a resignation letter submitted to payroll?(Required) Yes No Any equipment returnedKeys(Required) Yes No N/A Other Office, cupboard, pedestal etcDoor Entry/Access card(Required) Yes No N/A ID badges(Required) Yes No N/A Other Uniform(Required) Yes No N/A DoW Business Cards(Required) Yes No N/A Forwarding address details providedAddress(Required) Yes No N/A Address Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Telephone/mobile(Required) Yes No N/A Personal PhoneEmail(Required) Yes No N/A Personal Email ICT DepartmentDiocesan ICT property returnedLaptop, Bag & Charger(Required) Yes No N/A Other Mobile phone(Required) Yes No N/A Other Voicemail PIN(Required) Yes No N/A Other Anything else(Required) Yes No N/A Other DoW provided computer screens, mouse, keyboard, webcam, headset, desktop printer Department specific access accounts to be deletedPhotocopier/scanner(Required) Yes No N/A Other Network account(Required) Yes No N/A Other Only applies to Curia staffEmail account(Required) Yes No N/A Other Email account – To be kept open for 1 month for out of office purposes(Required) Yes No N/A If the account is to be kept for more than 1 month, a request must be made via the Data Protection Officer – dpo@rcdow.org.ukOut of office messageThis person has now left the diocese. This mailbox is no longer being monitored. Please redirect emails to email@rcdow.org.ukPlease enter the out of office message that you would like on the accountEmail account – Will someone need to access the mailbox?(Required) Yes No N/A If yes, the Data Protection Officer will be in touchFinancial SystemsDid the leaver have access to any of the following?DoW Credit Card(Required) Yes No N/A Microsoft GP(Required) Yes No N/A Sharperlight(Required) Yes No N/A OPAS(Required) Yes No N/A BankingHSBC signatory mandate – Are you an authorised HSBC signatory?(Required) Yes No N/A HSBCnet and HSBC red device – Do you have access to HSBCnet?(Required) Yes No N/A HSBCnet and HSBC red device – Do you have a HSBCnet red security device?(Required) Yes No N/A Business Internet Banking – Do you have access to HSBC BIB?(Required) Yes No N/A Do you have a HSBC Business Deposit Card assigned to you?(Required) Yes No N/A Other online access deactivatedResource centre(Required) Yes No N/A Other EduCare Online Training(Required) Yes No N/A Other Data Protection Online Training(Required) Yes No N/A Other DBD(Required) Yes No N/A Any other logins & passwords created on behalf of the diocesee.g. registering with HMRC, Charities Aid Foundation, Social media accountsAccountsOrganisationUsernamePassword Add RemoveYour DetailsName(Required) First Last Email(Required) Please enter your diocesan email address. You will receive a digital copy of this form.Consent(Required) I confirm that all the information in this form is correct.Signature(Required)
