Student Separation Form - Executive Office Shared Environment

Preparer Information

Preparer Name(Required)

Your name

First Last

Preparer UW Email(Required)

Your UW email address

Alternate Contact

In your absence, who should be contacted?

First Last

Alternate Contact UW Email

Alternate contact's UW email address

EO Assistance(Required)

Did you consult with or receive assistance from an Executive Office Shared Environment team member prior to filling out this form?

No

Yes

Team Member Name

First Last

Student Employee Information

Student Name(Required)

Name of employee who is separating

First Last

Student UW Email(Required)

UW email of employee who is separating

Student Unit(Required)

AP Sub-Units(Required)

ASA Sub-Units(Required)

DCCS Sub-Units(Required)

HSS Sub-Units(Required)

PRES Sub-Units(Required)

Action Request

Last Date of Employment(Required)

Student Separation Reason(Required)

Ending student status should be used in the case of graduation, withdrawal, or if the student no longer meets student employment eligibility requirements.

Ending student status

Resignation

Transferring to different UW department

New UW Department(Required)

Documentation

Upload any documentation that would be helpful to the EOHR team when reviewing this request.

Drop files here or

Accepted file types: pdf, doc, docx, jpg, jpeg, xls, xlsx, Max. file size: 15 MB, Max. files: 5.

Additional Information

Provide any additional, relevant information on needed action.