Departure Form SHS Departure Form Form for managers to fill out prior to employee departure date. Employee InformationEmployee Status* Full Time Part Time Per Diem Student Temp Full Name* First Middle Last Personal Email Address Primary Contact Number*(Mobile or Home Phone Number)BU ID Number(ex: U12345678) Is the employee leaving BU? Yes No Position DetailsSupervisor Name* Department Name*Athletic TrainingBehavioral MedicineFinance & AdministrationHealth Promotion & PreventionNutritionPatient ServicesPrimary CareSARPTechnology & OperationsPosition Title*Director, Student Health ServicesAssociate DirectorAdministrative CoordinatorInsurance AdministratorInsurance CoordinatorReferral CoordinatorOtherPosition Title*Assistant Director of Athletic Training ServicesAssistant Head Athletic TrainerAssociate Director of Athletic Training ServicesAssociate Head Athletic TrainerAssociate Head Athletic Trainer / Residency DirectorAthletic TrainerAthletic Trainer - Graduate AssistantAthletic Trainer Fellow – NeurologyAthletic Trainer Resident - Neurotrauma & SpineAthletic Trainer Resident – OrthopedicsAthletic Trainer Resident - Orthopedics & DiagnosticsAthletic Trainer, Academic FacultyAthletic Trainer, Academic Faculty, Coordinator of Clinical EducationDirector of AT Education ProgramsDirector of Athletic Training ServicesDirector of Sports MedicineMedical Director of Sports Medicine & Athletic TrainingOrthopedic SurgeonOrthopedic Surgeon - FellowPhysician - Neurotrauma ConsultantSports Medicine PhysicianSports Medicine Physician - FellowOtherPosition Title*Associate Director Outreach & Prevention ServicesCare CoordinatorClinical Social WorkerDirector BM & Associate Director Clinical ServicesEvaluation ClinicianMedical DoctorStaff PsychiatristStaff PsychologistStaff TherapistOtherPosition Title*Director, Health Promotion & PreventionGraduate Assistant, Health Promotion & PreventionCounselorProgram CoordinatorOtherPosition Title*Director of NursingMedical AssistantMedical DoctorNurse PractitionerRegistered NurseSenior Medical AssistantSenior Staff PhysicianStaff PhysicianTriage NurseOtherPosition Title*Administrative CoordinatorCrisis Intervention CounselorDirector, SARPHealth and Prevention EducatorOtherPosition Title*Registered DietitianStaff CoordinatorOtherPosition Title*Clinical Operations SpecialistDesktop SupportDesktop/Clinical Systems Specialist IIDirector, IT & Clinical SystemsLead Medical Records CoordinatorPatient Services CoordinatorOperations SpecialistOtherPosition Title*Patient Services CoordinatorPatient Services Assistant ManagerPatient Services ManagerDirector of Patient ExperienceOtherStudent Position Title*Graduate AssistantMaster's StudentOtherStudent Position Title*OtherStudent Position Title*OtherStudent Position Title*Alcohol and Drug Program FacilitatorCollegiate Recovery Program AssistantCommunications Graduate AssistantHealth Promotion Graduate AssistantMental Health Promotion Graduate AssistantPeer Leadership Graduate AssistantOtherStudent Position Title*EMTOtherStudent Position Title*SARP ActorSARP AmbassadorSARP Graduate AssistantSARP Peer EducatorOtherStudent Position Title*Desktop SupportOtherStudent Position Title*Front Desk StudentGraduate StudentOtherLast Day of Work* MM slash DD slash YYYY LocationOffice Address***For multiple selection: Hold down "Cntrl" key and click desired selection**Student Health Services (881 Commonwealth Ave)SARP or HPP (930 Commonwealth Ave)Fitrec (915 Commonwealth Ave)Agganis Arena (925 Commonwealth Ave)Case (285 Babcock St)BM BUMC (85 E. Newton St)Ryan Center (915 Commonwealth Ave)Nutrition (635 Commonwealth Ave)Office LocationEx. Office/Suite # Office Phone Number Technology/EquipmentHas BU issued IT equipment?* Yes No BU issued device*Check all that are applicable Mobile Phone Laptop Tablet (iPad) Other Other:*Please state specified device(s) if "other" was previously selectedHas PnC Token?* Yes No AdministrativeRequires Exit Interview? Yes No Has Malpractice Insurance? Yes No Has Keys?* Yes No Has Alarm Code?* Yes No Resignation LetterAccepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.Additional Comments