Rev. 5/7/08

Previous versions obsolete

**EMPLOYEE SEPARATION CLEARANCE INSTRUCTIONS**

The attached employee separation clearance form should be taken to the
organizations in the order shown below. This form must be returned to
the Federal Human Resources Branch (FHRB) on your last workday after all
signatures have been obtained. FHRB will complete the checkout process
and submit the clearance form to HQ payroll to assure that your final
salary check and lump sum annual leave payment may be issued. You cannot
receive your final pay check until FHRB receives the completed
separation clearance form from you and submits it to HQ Payroll.

Contact Amanda Hill in the Employee Health Station at (865) 241-2699 at
least [two weeks]{.underline} prior to your last day of employment if
you desire an exit physical.

**Send the following e-mail message to Information Resources Management
Division at [[IRMD@oro.doe.gov]{.underline}](mailto:IRMD@oro.doe.gov)
and to the Assessment and Emergency Management Team at
[Robinsonms@oro.doe.gov]{.underline} to assure employee databases remain
current by stating: a) "This is notification that I plan to leave DOE
employment on (mm/dd/yy). Please discontinue computer access (ORO
employees [only]{.underline}) and telephone voice messaging in my name."
b) Attach or include to the e-mail, a list of all tagged DOE computer
equipment (e.g., printers, scanners, CPU's monitors, laptops, PDA's
cameras, etc.) along with the associated "DOE Property" bar code number
(e.g., EA12345). A printed copy of the e-mail message (to include the
equipment) [must]{.underline} be attached to your Employee Separation
Clearance form when processing out.**

The following Oak Ridge Office employees/contractor personnel will
assist you in completing the sections identified below:

+------+---------------------+---------------------------+------------+
| **S  | **Assisting         | **Organization**          | **         |
| ecti | Employee(s)**       |                           | Location** |
| on** |                     |                           |            |
|      |                     |                           |            |
| **of |                     |                           |            |
| Fo   |                     |                           |            |
| rm** |                     |                           |            |
+------+---------------------+---------------------------+------------+
| Part | Betty Blackman, RN  | Federal Human Resources   | FOB Room   |
| I    |                     | Branch                    | 1207       |
+------+---------------------+---------------------------+------------+
| Part | Departing           | Departing employee's      | Varies     |
| II   | employee's          | organization              |            |
|      | supervisor (Branch  |                           |            |
|      | level or above)     |                           |            |
+------+---------------------+---------------------------+------------+
| Part | Emily Guffey        | Oak Ridge Financial       | FOB Room   |
| III  |                     | Service Center            | 2054-1     |
| A.   |                     |                           |            |
| and  |                     |                           |            |
| A-1  |                     |                           |            |
|      |                     |                           |            |
| (See |                     |                           |            |
| Note |                     |                           |            |
| B    |                     |                           |            |
| elow |                     |                           |            |
| [    |                     |                           |            |
| 1]{. |                     |                           |            |
| unde |                     |                           |            |
| rlin |                     |                           |            |
| e}/) |                     |                           |            |
+------+---------------------+---------------------------+------------+
| Part | Kathy Braden        | Oak Ridge Financial       | FOB Room   |
| III  |                     | Service Center            | 2033-4     |
| B.   | Rosa Trivette       |                           |            |
|      | (Alternate)         |                           | FOB Room   |
|      |                     |                           | 2057-5     |
+------+---------------------+---------------------------+------------+
| Part | Carol Jennings      | Procurement & Contracts   | FOB Room   |
| I    | (Government         |                           | 1040       |
| IIC. | Purchase Credit     |                           |            |
|      | Card)               |                           |            |
+------+---------------------+---------------------------+------------+
| Part | Training Center     | Training and Development  | FOB Room   |
| IV   |                     | Group (contractor         | G-110      |
|      |                     | support)                  |            |
+------+---------------------+---------------------------+------------+
| Part | Cathy Fallon --     | Information Resources     | FOB Room   |
| V.A  | **ORO employees     | Management Division       | B-3        |
|      | only**              |                           |            |
|      |                     |                           |            |
|      | Scott McGill        |                           |            |
|      | (Alternate)         |                           |            |
|      |                     |                           |            |
|      | Jim Thompson        |                           |            |
|      | (Alternate)         |                           |            |
+------+---------------------+---------------------------+------------+
| Part | Richard Dotson --   | Information Resources     | FOB Room   |
| V.B. | **ORO employees     | Management Division       | 2124-3     |
|      | only**              |                           |            |
|      |                     |                           |            |
|      | Gwen Senviel        |                           |            |
|      | (Alternate)         |                           |            |
+------+---------------------+---------------------------+------------+
| Part | Deanna Lowery       | Information Resources     | FOB Room   |
| V.C. |                     | Management Division       | 2124-3     |
|      | Lori Hamby          | (Contractor support)      |            |
|      | (Alternate)         |                           |            |
+------+---------------------+---------------------------+------------+
| Part | Michelle Lee --     | Office of Assistant       | FOB Room   |
| VI   | **ORO employees     | Manager for Security and  | B-031      |
|      | only**              | Emergency Management      |            |
|      |                     | (contractor support)      |            |
|      | Dale Keeney         |                           |            |
|      | (Alternate)         |                           |            |
|      | 576-1040            |                           |            |
+------+---------------------+---------------------------+------------+
| Part | **ORO employees     | Office of Assistant       | FOB --     |
| VII  | only** -- Kim       | Manager for Security and  | Ground     |
|      | Dodson at 576-0921  | Emergency Management      | Floor      |
|      | or Donna Daugherty  | (contractor support)      |            |
|      | at 576-6042,        |                           |            |
|      | **Appointment       |                           |            |
|      | Required**          |                           |            |
+------+---------------------+---------------------------+------------+
| Part | **ORO employees     | Office of Chief Counsel,  | FOB --     |
| VIII | only** -- Wendy     | Contracts and General Law | 3051-C     |
|      | Bryant (or          |                           |            |
|      | designee),          | ***(Required if GS-14 or  |            |
|      | 576-1210,           | above or if you've filed  |            |
|      | **Appointment       | a Financial               |            |
|      | Required**          | Disclosure)***            |            |
+------+---------------------+---------------------------+------------+
| Part | Cathy Clifton (865) | Federal Human Resources   | FOB 1221   |
| IX   | 576-0680            | Branch                    |            |
|      |                     |                           |            |
|      | Sherry Stotelmyer   |                           |            |
|      | (865) 576-0669      |                           |            |
+------+---------------------+---------------------------+------------+

[1]{.underline}/ All travel documents and receipts for the last 120 days
prior to separation must be submitted to ORFSC in order to receive
clearance from ORFSC under this Part.

+------------+---------------------------------------------------------+
| ORO F      | **DEPARTMENT OF ENERGY**                                |
| 3000.1     |                                                         |
|            | **EMPLOYEE SEPARATION CLEARANCE**                       |
| Previously |                                                         |
| OR-86      |                                                         |
|            |                                                         |
| Rev.       |                                                         |
| 5/7/08     |                                                         |
|            |                                                         |
| Previous   |                                                         |
| editions   |                                                         |
| obsolete   |                                                         |
+------------+---------------------------------------------------------+

+-------------------------------------+---------------+----------------+
| Name (Last, First, MI)              | Last Day of   | Type of        |
| Organization:                       | Work (or Last | Separation:    |
|                                     | Day on        |                |
| Forwarding Address:                 | Employment    |  Retirement  |
|                                     | Rolls:        | Resignation    |
|                                     |               |                |
|                                     |               |  LWOP         |
|                                     |               |                |
|                                     |               |  Transferring |
|                                     |               | to:            |
|                                     |               |                |
|                                     |               |  Other:       |
+-------------------------------------+---------------+----------------+

**PART I. EMPLOYEE HEALTH STATION**

 I want my medical records copied, mailed to me, and I have completed
the necessary form for this transaction.  I [do not]{.underline} want
my medial records copied and mailed to me.

Date: Signature of Health Station Official: [.]{.underline}

**PART II. CERTIFICATION OF EMPLOYING OFFICE**

 After examination of appropriate records, I certify that the employee
is not charged with any Research and Development reports or other
classified or non-classified documents, books, periodicals, equipment,
or supplies. No federal records may be removed from DOE by a departing
employee. I also certify the employee  is  is not currently involved
in the conduct of procurement expected to result in a contract or
modification in excess of \$100,000, as defined by the Procurement
Integrity requirements of Public Law 100-679.

Date: Signature of Supervisor: [.]{.underline}

**PART III.A. ACCOUNTS PAYABLE - TRAVEL**

 Government Travel Credit Card Returned  Government Travel Credit Card
Not Issued  Vouchers Cleared  Advances Cleared  Last 120 Days Travel
Documents Obtained  Service Agreement(s) (specify purpose):  Satisfied
 Not Satisfied

Indebtedness (specify): [\_]{.underline}

**Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Signature of
Accts. Payable Travel Official:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**PART III A-1. ACCOUNTS PAYABLE -- APPROVING, PROGRAM, SPECIALIST
OFFICIAL IN STARS (If Applicable)**

**Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Signature
of ORFSC Official:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**PART III.B. ACCOUNTS PAYABLE - PAYROLL**

Clearance granted or deductions made in final check for following items:

 Clearance Granted  Leave Indebtedness  Service Agreement (specify
purpose)  Satisfied  Not Satisfied

Indebtedness (specify): [\_]{.underline}

**Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Signature
of Payroll Official: [\_]{.underline}**

**PART IIIC. ACCOUNTS PAYABLE -- GOVERNMENT PURCHASE CARD (If
Applicable)**

 Government Purchase Credit Card Returned  Government Purchase Credit
Card Not Issued

**Date:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Signature of Accounts Payable Official:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**PART IV. ACTION OF TRAINING AND DEVELOPMENT GROUP**

 Proper documentation for training complete.  Proper documentation for
training incomplete.\*

**Date: Signature of Training Official: [.]{.underline}**

\* I understand that if proper documentation for training courses is
incomplete, those training courses will not be recorded in my Official
Personnel File.

**Date: Signature of Employee: [.]{.underline}**

**PART V.A. ACTION OF INFORMATION RESOURCES MANAGEMENT DIVISION (IRMD)
FACILITY MANAGEMENT (Room B03)**

Calculator  Not Issued  Motor Vehicle  Not Issued  Building Key 
Not Issued

 Briefcase  Not Issued  Property Pass  Not Issued  Keyless Access
Code  Not Issued

 Dictating/Transcriber  Not Issued  Desk Lamps  Not Issued  Safe
Combinations  Not Issued

 Ergonomic Chair  Not Issued  Mobile Phone  Not Issued  Heaters/Fan
 Not Issued

 Recorder  Not Issued

**Date: Signature of IRMD Official: [\_ ]{.underline}**

**PART V.B. INFORMATION RESOURCES MANAGEMENT DIVISION (IRMD)-
INFORMATION TECHNOLOGY MANAGEMENT (Room 2124)**

**[Computer Equipment and Remote Devices]{.underline}**

Laptop Computer  Obtained from employee  Not Issued

PDA  Obtained from employee  Not Issued

Blackberry  Obtained from employee  Not Issued

Flash Drives  Obtained from employee  Not Issued

RSA SecurID Token  Obtained from employee  Not Issued

IT Equipment on Loan  Obtained from employee  Not Issued

IT Equipment used for Work At Home  Obtained from employee  Not Issued

E-mail notification requesting closure of Computer Accounts  Obtained
from employee  Not Received

Printed copy of transfer of any sensitive equipment (i.e., CPU, 
Obtained from employee  Not Received

monitor, printer, scanner, facsimile) Misc. Hardware/

Software (i.e., zip drive, non-supported software)

**Date: Signature of IRMD Official: [\_\_\_\_\_\_\_ ]{.underline}**

I have reviewed all computer equipment and devices that I was assigned
while employed by the Department of Energy. No equipment or device
contains Personally Identifiable Information (PII). I certify that I
have not collected or retained PII obtained from the Department of
Energy at alternate locations for any purpose.

**Date: Signature of Employee: [\_\_\_\_\_\_\_ ]{.underline}**

**PART V.C. INFORMATION RESOURCES MANAGEMENT DIVISION (IRMD) -
INFORMATION TECHNOLOGY MANAGEMENT (Room 2124)**

**[Telecommunications]{.underline}**

Telephone credit cards:  Obtained from employee  Not issued

Cellular Phone:  Obtained from employee  Not Issued

Pager:  Obtained from employee  Not Issued

Mobile Phone:  Obtained from employee  Not Issued

Radio:  Obtained from employee  Not Issued

E-mail notification  Received from employee  Not Received

**Date: Signature of IRMD Official: [\_\_\_\_\_\_\_ ]{.underline}**

**PART VI. CLASSIFIED DOCUMENT CONTROL**

Classified document inventory completed and all secret documents
returned to the Central Library.

**Date: Signature of Central Library Official:
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
]{.underline}**

**PART VII. SECURITY BRIEFING** - ***APPOINTMENT IS REQUIRED***

Security termination briefing conducted and Termination Statement (DOE F
5631.29) signed.  **YES**  **Not required**

Other special briefings (cryptographic, NATO, FIl, etc.) conducted and
briefing forms signed.  **YES (specify special briefing )**  **Not
required**

All security badges, passes, and/or identification cards returned.

**Date: Signature of Security Official:
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
]{.underline}**

**PART VIII CHIEF COUNSEL -- *APPOINTMENT IS REQUIRED***

 SF-278 Report of Financial Interest (required for all employees paid
at a rate of GS-14 (or equivalent) or above.

 OGE-450, Financial Disclosure is required of all separating employees
who have filed a financial statement and are not required to file a
SF-278

**Date: Signature of Legal Official:
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
]{.underline}**

**PART IX.** **ACTION OF PERSONNEL OFFICE**

 Verbal Exit Interview Conducted by Primary HR Contact

 Exit Survey Provided to Employee

 SF-8, Unemployment Compensation Notice Issued

 Retirement SF-2810, Health Benefits Issued

 SF-2821, Life Insurance Status Issued

 SF-2819, Conversion Privilege Issued

 Memo Issued Regarding, Restrictions Relating to Future Employment
(upon retirement or buyout)

 Retiring and must provide medical coverage for children by court
order: has provided copy of court order to personnel office

 Service Agreement(s) (specify purpose)  Satisfied  Not Satisfied 
Not Applicable

**Date: Signature of Human Resources Official: [. ]{.underline}**

**Date: Signature of Employee: [. ]{.underline}**