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Employee Portal
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Employee's Name
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First
Last
Last physical day of work?
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Separation date?
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Position / Job Title
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Who discharged the claimant – name and job title?
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What was the reason given to the claimant for the discharge?
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What was the date of the final incident?
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What was the final incident that resulted in the separation?
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How did the employer become aware of this incident?
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What is your understanding of what happened?
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Was it confirmed/investigated – how?
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Did the claimant admit, deny or provide an explanation for the violation?
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If terminated for job performance, were they ever able to perform the job to the employer’s expectations?
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Was the inadequate performance due to carelessness or negligence?
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Yes
No
Unsure
Were they on a performance improvement plan?
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Yes
No
Unsure
What rule, policy or policies did they violate?
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How would the claimant have known about the policy?
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• Why did this last incident warrant immediate discharge versus a lesser form of disciplinary action?
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What is the harm caused by the claimant’s conduct? (What effect does it have on the company, fellow employees, etc.?)
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Had the claimant had previous occurrences or been warned for similar conduct?
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Yes
No
Unsure
If so, please provide the following for each warning: Date, type of warning (verbal/written/final), who gave it and the incident/reason for warning.
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