Student Separation Form Step 1 of 3 33% Preparer InformationPreparer Name(Required)Your name First Last Preparer UW Email(Required)Your UW email address Alternate ContactIn your absence, who should be contacted? First Last Alternate Contact UW EmailAlternate 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 InformationStudent Name(Required)Name of employee who is separating First Last Student UW Email(Required)UW email of employee who is separating Student Unit(Required)-CHOOSE ONE-Academic Personnel (AP)Academic and Student Affairs (ASA)President (PRES)Provost (PROV)Faculty SenateHealth Sciences Services (HSS)Division of Campus Community Safety (DCCS)AP Sub-Units(Required)-CHOOSE ONE-AP: CoreAP: Ops, AHR, PIMAP: Ops ISOAP: Faculty AdvancementASA Sub-Units(Required)-CHOOSE ONE-ASA: Academic Technologies (AT)ASA: AdmissionsASA: AdvancementASA: Center for Teaching and Learning (CTL)ASA: CoreASA: Financial AidASA: Information Services (ASA-IS)ASA: International Student ServicesASA: RegistrarASA: Strategic InitiativesDCCS Sub-Units(Required)-CHOOSE ONE-DCCS: CoreDCCS: SafeCampusDCCS: Emergency ManagementDCCS: UWPDHSS Sub-Units(Required)-CHOOSE ONE-HSS: Academic Services & Facilities (AS&F)HSS: CoreHSS: Interprofessional Education (IPE)PRES Sub-Units(Required)-CHOOSE ONE-PRES: Board of Regents (BOR)PRES: CorePRES: Environmental Health & Safety (EH&S)PRES: Internal Audit (IA)PRES: OmbudPRES: Population HealthPRES: University Rules & PolicyPRES: UWINCO Action RequestLast Date of Employment(Required) MM slash DD slash YYYY 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) DocumentationUpload any documentation that would be helpful to the EOHR team when reviewing this request. Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, jpeg, xls, xlsx, Max. file size: 15 MB, Max. files: 5. Additional InformationProvide any additional, relevant information on needed action.