Account Termination Form
Employee Information
User's Name
*
First Name
Last Name
User's Email
*
example@example.com
Retain Email
*
Yes
No
Reporting Manager's Email
example@example.com
Job Title
Location
Please Select
Administration I
Administration II
CA ST
Channel
Channel Modular
Delta College
Dixon
Dorothy Jones
East Main St.
East March Lane
Gleason House
HR Annex
Lawrence
Lodi Turner
Lodi Vine
Lodi WIC
Manteca
Mariposa
Medical Records Warehouse
MCRT Office
Respite Center
Rock Annex
St. Mary's
Stockton WIC
Sutter Street
Tracy Central
Tracy Dental
Tracy Grant Line
Tracy WIC
TUSD Wellness Center
Vacaville
Vacaville Dental
Vacaville Pediatrics
Waterloo
Weberstown
Weberstown Dental
87 Weberstown Medical
Department
Please Select
Administration
Applications Team
Behavioral Health (BH)
Billing
Board Members
Business Intelligence (BI)
CareLink
Communications
Compliance
COVID Team
CPSP
Dental
Dental Transformation Initiative (DTI)
Early Intervention Services (EIS)
Environmental Safety
Executive
Experience / Training
Facilities
Finance
Float Team
Front Desk
Grants
Health Ed
Health Equity
Human Resources (HR)
Information Systems (IS)
Medical
Medical Records
MCRT
Nursing
Operations
Outreach & Enrollment (O&E)
Patient Services Center (PSC)
Pharmacy
Population Health
Programs
Quality Improvement (QI)
Radiology / X-Ray
Recovery
Referrals
Residency
RX Refill
Scheduling
Transition of Care (TOC)
WIC
Completed By (HR Staff)
First Name
Last Name
Effective Termination Date
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Submitted
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Email and Network Drive Processing
Email Retention: Per Microsoft's Retention policy, emails for disabled accounts are retained for 30 days.
Forward Email
Yes
No
Who needs to receive the emails?
*
First Name
Last Name
Access to Mailbox
Yes
No
Who needs access to the user's mailbox?
*
First Name
Last Name
OneDrive Access
Yes
No
Who needs access to the user's OneDrive?
*
First Name
Last Name
File Share
H: Drive
Yes
No
Who needs access to the user's H: Drive?
*
First Name
Last Name
Equipment
IMPORTANT: All computer equipment must be returned to the IS Department. If interofficed, please included employee's name.
Was user-issued equipment?
*
Yes
No
Equipment Type
*
Desktop/Laptop
Cell Phone
Monitor(s)
iPad
Docking Station
Other
Equipment Details (If multiple devices, separate by commas.)
*
Phone Details
Equipment returned?
*
Yes
No
Returned to:
example@example.com
Comments
Account Cleanup
Check the following once completed:
Disable AD Account
Add Termination Date to AD Description
Remove User from All AD Groups
Move userdocs folder
Move OneDrive Contents
Complete Termination Request
Email Cleanup
Check the following once completed:
*
Forward Emails
Grant Access to Mailbox
Completed by (Technician)
First Name
Last Name
Completed
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: