Exit Interview

NAME

DATE

MM slash DD slash YYYY

JOB TITLE

DEPARTMENT

EMPLOYMENT START DATE

EMPLOYMENT TERMINATION DATE

PHONE NUMBER

FORWARDING ADDRESS

Street Address City 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

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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