Caldwell County Schools Resignation/Retirement Form

Caldwell County Schools Resignation/Retirement Form

Must be completed by employee
Name*

First NameLast Name
Your email*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor Name*

First NameLast Name
Supervisor Email*
I wish to resign/retire as an employee of Caldwell County School System effective at the close of the day on*

MonthDayYear
My current location is*
My specific assignment is*
I will be transferring to the following NC State Agency (if applicable)
Reason for leaving employment (please be as specific as possible)*
If you are a certified employee, please select the best response for why you are resigning/retiring:

Teach in another districtTeach in another stateMoved to a non-teaching position in educationTeach in NC charter schoolTeach in non-public school/private schoolFamily responsibilities/child-care issueContinue EducationFamily relocation and you will be leaving educationDissatisfied with teaching/educaitonCareer change (will no longer work in education)Health issues or disabilityRetirementOther
The following questions will only be visible to members of the HR staff:
How many years have you worked in Caldwell County Schools?*
Please enter the year
How would you rate your employment experience with Caldwell County Schools?*
How would you rate the quality of supervision that you received from your school or location administration?*
How would you rate the level of support given to you by the Caldwell County Schools Education Center?*

How likely are you to seek a job with Caldwell County Schools in the future?*

	1	2	3	4	5

1 is Not likely, 5 is Highly likely

Is there anything that Caldwell County Schools could have done to prevent your resignation?*
Do you have any concerns about your employment in Caldwell County Schools that you would like to share?*
Would you like a member of the human resources department to contact you for an exit interview?*

YesNo
Continuation of Benefits
Health and Dental Insurance

Continuation of coverage is available to you. Both of these companies will send you a COBRA packet to your home address. If you have questions and/or need to update your home address, please contact these companies at the customer service number located on your insurance card.
Life Insurance

Portability and conversion coverage is available to you through Reliance Standard Life Insurance Company. If interested, you may contact them at 1-800-351-7500.
Supplemental Insurance Policies

Continuation of coverage is avalable to you. A packet will be sent to your home address. If you have any questions, please contact Pierce Group Benefits at 1-800-325-4368.
Vision Insurance Policies

Continuation of coverage is not available.
Signature

Clear
Date

MonthDayYear
Should be Empty:

Caldwell County Schools Resignation/Retirement Form

Continuation of Benefits