Employee Relations Specialist

Separation Notice

Employer Information

Company: LAKE CHARLES MEMORIAL HOSPITAL

Company Street Address 1: 1701 Oak Park Blvd

Address 2:

City: Lake Charles

State: LA

Zip: 70601

Name: SBuie

Title: Employee Relations Specialist

Phone Number: 337-***-****

Email Address: ad0xlb@r.postjobfree.com

Employee Information

Employee First Name: Paul

Employee Last Name: Papillion

Employee SSN: xxx-xx-3193

Employee Date of Separation: 06/06/2023

Employee Date Hired: 2/23/2023

Employee Date Last Worked: 5/25/2023

Separation Reason

Reason For Separation: Terminated / Fired

Explain Reason for Separation: Policy Violation

Benefit Payments

Hourly Rate of Pay: $14.85 Hours Worked Per Week:40 Vacation/Accrued Leave - Not PTO : No Total Amount: Number of Hours: 0 Severance/Dismissal: No Total Amount: Number of Hours: 0 Bonus: No Total Amount: Number of Hours:0

Holiday Pay: No Total Amount: Number of Hours:0

Wage in lieu of Notice: No Total Amount: Number of Hours:0 Pension: No

If lump sum, what would the monthy amount

be if that option had been choosen?

I certify that the worker whose name and Social Security Number appear above has been separated from work and that the above information is true and correct. I further certify that the individual has been handed or mailed a copy of this notice.

This form has been submitted electronically. There is no need to mail a copy to Louisiana Workforce Commission

IMPORTANT: Give a copy of this form to the separating worker and retain a copy for your files. Signature Date

Separation Notice (Form 77) Submitted to HiRE 6/8/2023 3:16:53 PM

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