Policy Manual sample

MDT Home Health Care Agency, Inc. RESIGNATION NOTICE FORM EMPLOYEE: ______________________________________________ DATE: _____________ I, _______________________________ hereby resign my position as of_________________________ (Printed Name) (last day to work) I am giving the following notice: _______ Two (2) weeks notice as requested of my position. (Initial) _______ Four (4) weeks notice, as requested of my position. (Initial) _______ Other, as described: _____________________________________________________ ( Initial) Reason: _____________________________________________________________________ ____________________________________________________________________ ________I desire information on 401K rollover. (if applicable) (Initial) If less than requested notice, I understand I will forfeit my PTO pay out, as described in MDT Home Health Care Agency, Inc. Policy. I also understand I will forfeit my eligibility for rehire with MDT Home Health Care Agency, Inc. ____________________________________________________ ___________________ Employee Signature Date Supervisor Approval (INITIAL): 1) Accept the resignation with the following modifications: ________ Employee is not required to serve notice time. PTO will be paid out per policy. Employee is eligible for rehire. ________ Employee is required to serve ______________ notice period. PTO will be paid out per policy. Employee is eligible for rehire. _________ Accept the resignation as given by employee. ______________________________________________________ ___________________ Supervisor Signature Date _____________________________________________________ ___________________ Director of Nursing, Clinical Manager Date Note: PTO may not be taken during notice time. Home Health Agency. - - Personnel/Operations Policies B-54