Exit Interview
NAME
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DATE
MM slash DD slash YYYY
JOB TITLE
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DEPARTMENT
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EMPLOYMENT START DATE
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EMPLOYMENT TERMINATION DATE
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PHONE NUMBER
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FORWARDING ADDRESS
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Briefly explain your reason for leaving:
Which of the following were important in influencing your decision to resign? (More than one may apply)
Disliked job duties
Dissatisfied with pay
Dissatisfied with benefits
Working conditions
Supervisor
Conflict with co-worker(s)
No advancement opportunities
Returning to school
Moving
Career change
Health problems
Care for family member
Transportation problems
Other (specify below)
Other reason
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Is there pay of any kind owed to you?
No
Yes
If yes, please explain
Describe the aspects of your job which you enjoyed most.
Describe the parts of your job which you enjoyed least.
What employee benefit(s) did you value most?
What employee benefit(s) did you value least?
What could your supervisor have done to help you perform your job better?
What are your thoughts about the training provided to you?
What are your suggestions for improving communication within the organization?
Please let us know of any suggestions to make this a better place to work.
Knowing what you know now, if you were to apply for a job here would you want to work in the same job?
Yes
No
Knowing what you know now, if you were to apply for a job here would you want to work in the same department?
Yes
No
Knowing what you know now, if you were to apply for a job here would you want to work for the same manager/supervisor?
Yes
No
Additional comments:
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