Separation Rating

EMPLOYEE'S FIRST NAME

EMPLOYEE'S LAST NAME

CLASSIFICATION

COUNTY AGENCY

This rating is to be made when any permanent or probationary employee leaves employment with the agency for any reasons other than death or retirement. Submit this form with the Report of Personnel Action (DHS-0852).

Evaluate the employee taking into account the employee's performance evaluations.

Satisfactory

Unsatisfactory

Attach documentation for an unsatisfactory rating. This could include the employee's most recent performance appraisal in this class showing an overall unsatisfactory rating or if the actions leading to the unsatisfactory rating occurred between the last appraisal and separation from the classification, fill in the section below, describing why the job performance was unsatisfactory and what actions were taken to correct or discipline the employee.

SUPERVISOR'S COMMENTS

Supervisor

By checking this box and typing my name in the "Electronic Signature" field, I understand that I am electronically signing this form. In addition, I attest and certify that the information provided above is true and accurate. I understand that my electronic signature has the same legal effect and can be enforced in the same way as a handwritten signature. (MN Stat. §325L.07)

SUPERVISOR'S ELECTRONIC SIGNATURE

DATE

Send a confirmation and copy of this form to the submitter

Enter an email address below and a confirmation, including a PDF file of the information provided, will be sent

Send a confirmation and copy of this form to the director

Enter an email address below and a confirmation, including a PDF file of the information provided, will be sent to the director

Does employee need to review and sign this form?

Yes

EMPLOYEE'S EMAIL ADDRESS

Does agency director need to review and sign this form?

Yes

AGENCY DIRECTOR'S EMAIL ADDRESS

Employee

I certify that I have seen this form as completed. (Signature does not mean that you agree with the employer's ratings or comments. Any disagreement or comments may be noted below.) By checking this box and typing my name in the "Electronic Signature" field, I understand that I am electronically signing this form. In addition, I attest and certify that the information provided above is true and accurate. I understand that my electronic signature has the same legal effect and can be enforced in the same way as a handwritten signature. (MN Stat. §325L.07)

EMPLOYEE'S ELECTRONIC SIGNATURE

DATE

EMPLOYEE COMMENTS

Agency Director

AGENCY DIRECTOR'S ELECTRONIC SIGNATURE

DATE

GUIDEmployee

GUIDDirector

DHS Use Only

DHS ACTION

APPROVED BY

APPLICATION ID

POSITION NUMBER

CLASS CODE

Form State Cd

You signature has already been received. This form cannot be submitted again.