Circular Exhibit 2013-06-B
| Employee Name: Jane B. Doe |
Last 4 Digits SSN: XXX-XX-0000 |
Timekeeper Number: 12345 |
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| Organization and Work Location: Indian Health Service Office, Building, and Office Suite Number, City, State, Zip Code |
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___X___ Separating from Federal Government
______ Transferring to another IHS component or Federal Agency (Specify) __________________________________________ Date of Separation or Transfer:_May 31, 2013_ |
Forwarding Address:
Rt. 1, Box 18 Winnebago, NE 68071 Optional: Home Phone Number Optional: Home Email Address
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| Clearance Items | Received | Comments | Accountable Office for Final Disposition (Initials and date) |
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| x | IT Access Control Removed (Network-Email - RPMS) | Y N N/A | ____________________________________ |
OIT______________________
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| x | Advanced Leave Resolved | Y N N/A | ____________________________________ |
DHR______________________
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| x | PIV Card Returned | Y N N/A | ____________________________________ |
DAS______________________
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| x | Non-PIV Facility Access Cards Returned | Y N N/A | ____________________________________ |
DAS______________________
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| x | Keys Returned | Y N N/A | ____________________________________ |
DAS______________________
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| x | Official Files/Record Returned | Y N N/A | ____________________________________ |
DHR______________________
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| x | Government Purchase Card (PCard) Returned | Y N N/A | ____________________________________ |
DFO______________________
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| x | Travel Card Returned | Y N N/A | ____________________________________ |
DFO______________________
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| x | Outstanding Travel Advance Resolved | Y N N/A | ____________________________________ |
DFO______________________
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| x | Outstanding Travel Voucher Resolved | Y N N/A | ____________________________________ |
DFO______________________
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| x | E-Gov Travel Service Access Removed | Y N N/A | ____________________________________ |
DFO______________________
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| x | Library Books/Card Returned | Y N N/A | ____________________________________ |
DAS______________________
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| x | UFMS Access Removed | Y N N/A | ____________________________________ |
OFA______________________
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| x | Government Hang Tag/Parking Sticker Returned | Y N N/A | ____________________________________ |
DAS______________________
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| x | Government Phone cards Returned | Y N N/A | ____________________________________ |
DAS______________________
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| x | Government Emergency Telecommunications Service (GETS) card Returned | Y N N/A | ____________________________________ |
DAS______________________
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| x | Government Cell Phone Returned | Y N N/A | ____________________________________ |
DAS______________________
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| x | Smart Phone, Palm Pilot, Blackberry, iPhone Returned | Y N N/A | ____________________________________ |
OIT/DAS__________________
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| x | Laptop Computer Returned | Y N N/A | ____________________________________ |
OIT/DAS__________________
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| x | Government Pager Returned | Y N N/A | ____________________________________ |
DAS______________________
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| x | Other Government Furnished Equipment Returned | Y N N/A | ____________________________________ |
DHR______________________
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| x | Separation Date Entered into ITAS | Y N N/A | ____________________________________ |
DHR______________________
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| x | Supervisor Initiated Capital HR Appropriate Action | Y N N/A | ____________________________________ |
Supervisor________________
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| x | Capital HR Request Approved | Y N N/A | ____________________________________ |
DHR______________________
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| x | Action Tracking System (ATS) Access Removed | Y N N/A | ____________________________________ |
ESS______________________
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| x | E-WITS Access Removed | Y N N/A | ____________________________________ |
DHR______________________
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| x | PRISM Access Removed | Y N N/A | ____________________________________ | DFA______________________ |
- Under Comments, list the Office that was sent the item or notified about clearing it. Accountable Offices may differ.
- If the employee is not willing to sign the clearance sheet, not present, or deceased, the supervisor should locate all equipment assigned to the employee and account for each piece on the clearance sheet. For any missing items take the appropriate action.
Distribution: Completed original to the Director, Division of Human Resources or the Regional Human Resources Office
1 copy to the employee
1 copy to the supervisor
Additional Comments
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I certify that I do not have IHS property or records in my possession and that I am not indebted to the IHS.
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I certify that I have completed this form and that I have verified that all required clearances have been obtained.
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Signature of Employee Date
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Signature of Supervisor Date
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