Leaver and Exit Interview Form Please complete without delay to prevent over payments SECTION 1 EMPLOYEE’S DETAILS (For completion by Line Manager/Supervisor) Surname Post Title Forename (s) Work Base Employee No. Date Notice Received 1 Last Working Day 4 Any Annual Leave not incorporated in Hours/Days* box 3 which will need to be paid. (Payroll will do a manual adjustment on final salary) – 2 Annual Leave being taken after last 5 Any Annual Leave taken in excess of Hours /Days* working day and prior to last day of Hours/Days* entitlement. Payroll will make a manual paid service deduction from final salary –

3 Last Day of Paid Service (add number HR Payment in Lieu of Notice: of annual leave hours/days to last Use working day to get this date taking into Only account shift/rota pattern) Fixed Working Pattern Details: Shift Pattern (if applicable) Days Worked Hours Days Worked Hours If hours worked on rota please detail shift pattern below: Worked Worked Sunday Thursday Monday Friday Tuesday Saturday Wednesday Future Correspondence Details: Address Telephone

SECTION 2 ADDITIONAL DETAILS (For completion by Line Manager and Employee)

All posts to be terminated? Yes / No Please delete as If No please provide appropriate details: Arrangements made for HCT property/Smartcard/ Yes / No prescription pads to be returned where applicable Please delete as appropriate Is the employee an Authorised Signatory? Yes / No Please delete as Employee offered Exit Yes / No/ Declined Please delete appropriate Questionnaire? as appropriate SECTION 3 REASON FOR LEAVING (For completion by Line Manager/Supervisor) DISMISSAL END OF CONTRACT VOLUNTARY RESIGNATION Bank Staff not fulfilled min work required Capability End of Fixed Contract Adult Dependants Conduct Completion of Fixed Training Scheme Child Dependants Statutory Reason External Rotation Better Reward Package Other Substantial Reason End of Work Requirement Lack of Opportunities Other Health OTHER Work Life Balance Employee Transfer RETIREMENT Relocation TUPE transfer into another organisation Initial Pension Ended Promotion Pregnancy Age Further Education Death in Service Ill Health REDUNDANCY Other / Not Known Voluntary Early Retirement Compulsory Flexible Retirement Voluntary SECTION 4 DESTINATION ON LEAVING (For completion by Line Manager/Supervisor) NHS Organisation * Prison Service Other Private Sector General Practice Other Public Sector Abroad – Non-EU Country Education Sector Abroad – EU Country Social Services Self Employed Return to Practice Armed Forces Education/Training Private Health/Social Care No Employment

* NHS Organisation (if applicable)

Employee’s Signature Date Manager’s Signature (authorised Date signatory only please) Manager’s Name in Block Capitals Manager’s Contact Phone Number I understand that personal data collected on this form will be used by HCT to maintain or update my employment and occupational health records, and for payroll purposes, as well as for analysis for management purposes and statutory returns. HCT undertakes that any processing or disclosure of personal data by the HCT will be in line with the Data Protection Act 1998 requirements

ACTIONED BY: HR team Date Payroll Date CHECKED BY: HR team Date EXIT QUESTIONNAIRE

An anonymous exit questionnaire is also available at: https://www.surveymonkey.com/r/hctleaversquestions

REASONS FOR LEAVING

Why are you leaving?

What could we have done to retain you?

THE FUTURE

What are you doing next?

If further employment, what attracted you to your new job?

HERTFORDSHIRE COMMUNITY NHS TRUST (HCT)

Which parts of your role did you enjoy?

Which parts of your role did you not enjoy/find frustrating?

At what point did you become dissatisfied with the Trust and decide to leave?

Do you feel you received the appropriate support to enable you to do your job?

How well were your Learning and Development needs assessed and met?

Are there any changes to HCT that you would recommend?

Would you recommend HCT as an YES / NO employer?

NEXT STEPS

If you have any additional issues you wish to raise, you can either submit an additional sheet or a further interview can be arranged with a member of the Human Resources team. If you would like this to be arranged, please provide a contact number for a further interview :

Please return this form as soon as possible via fax or scanned copy to: HCT Resourcing Team, Unit 1a Howard Court, 14 Tewin Road, Welwyn Garden City, AL7 1BW Fax Number: 01707 326718 Notification of retirement requires at least 3 months notice. LEAVER FORM GUIDELINES

Leaver Form ESR 6.7 is to be used when employee notifies their intention to physically leave the Trust or if an assignment is to be terminated - not where an employee is moving between services (a change of circumstances form can be used).

Form is available on the intranet at www.hertschs.nhs.uk / staff-area/ Forms and Templates/ HR Forms and Templates

Provide member of staff with Exit Questionnaire if leaving the Trust.

Form is available on the intranet at www.hertschs.nhs.uk / staff-area/ Forms and Templates/ HR Forms and Templates

Member of staff to return completed Exit questionnaire to relevant HR Team.

Complete Leaver Form ESR 6.7 as soon as notice is received. All termination details are mandatory and MUST be completed, along with reason for termination and future address. ALL sections of the form are mandatory.

Guidance on Section 1 Employee’s Details Always check the last day of paid employment (# 3) reflects the last working day (# 1) plus any leave days (#2)(taking into account shift/rota pattern). For example, Full time leaver with no rota/shift pattern • Last working day (# 1) (date last physically in work) = 1 August • Leave owing (# 2) (leave not taken in notice period but entitled to) = 4 days • Last day of paid service (# 3) (date once all leave owing is used) = 5 August (that is, 1st August + 4 days)

For example, Part time leaver who works 20 hours a week, shift Pattern: Monday 7.5hrs/Wednesday 5hrs/Thursday 7.5hrs • Last working day (# 1) (date last physically in work) = 10 February • Leave owing (# 2) (leave not taken in notice period but entitled to) = 22.5 hours • Last day of paid service (# 3) (date once all leave owing is used) = 19 Feb (that is, 10 February + 20 hrs due to work pattern) • Leave not incorporated in # 3 to be paid (# 4) (annual leave to be paid) = 2.5 hours

If an employee is leaving to be employed to another NHS Organisation the last day of paid service should be a Sunday (as long as last day of work or annual leave would have been a Friday).

When an employee has taken in excess of annual leave payroll will make a manual adjustment to the final salary (number of hours to be deducted from final salary should be listed in # 5 on leaver form). This will result in the last working day and last day of paid service to be the same unless last day of paid service is extended to Sunday due to continuous employment in NHS.

Ensure the form is signed and dated by the employee and an authorised signatory.

NB Incomplete / illegible forms and older versions of forms will be returned to the line manager and will not be actioned. This may result in incorrect payments and, where applicable, a delay in pension arrangements being made.

Fax completed form to the HR Team:

Unit 1a Howard Court, 14 Tewin Road, Welwyn Garden City, Herts, AL7 1BW Fax Number: 01707 326 718

Complete ICT’s Computer Systems Leaver Notification Form (CSAL) through the extranet as soon as notice is received if the employee is leaving the Trust.

Authorised managers can log on and complete the form here: http://char-db01:423/ict/index.php/it-forms