CONFIDENTIAL

EMPLOYEE EXIT INTERVIEW FORM

Date
: ___________________________
Name
: ___________________________
Index
: ___________________________
Location/ Department : ___________________________ Supervisor :
___________________________
Hiring Date
: ___________________________ Termination date
___________________________
Starting Position : ___________________________ Ending Position
:
___________________________
Starting Salary
: ___________________________ Ending Salary
___________________________

PART I : REASON FOR LEAVING

More than one reason may be given if appropriate; if so, circle primary reason
RESIGNATION
- Took another position
- Dissatisfaction with type of work
- Pregnancy/ home or family needs
- Dissatisfaction with supervisor
- Poor health/ physical disability
- Dissatisfaction co workers
- Relocation to another city
- Dissatisfaction with working
- Travel difficulties
condition
- To attend school
- Dissatisfaction with benefits
- Dissatisfaction with salary
- Other (Specify) :
- ________________________________________________________________________________
___
- ________________________________________________________________________________
___
LAID OFF
RETIREMENT
- Lack of work
- Voluntary retirement
- Abolition of position
- Disability retirement
- Lack of funds
- Regular retirement

Others :
________________________________________________________________________________
___________________________________________________________________________________
___

Plans After Leaving:

______________________________________________________________________________________
______
______________________________________________________________________________________
______
______________________________________________________________________________________
______

PART II : COMMENTS/ SUGGESTIONS FOR IMPROVEMENT

We are interested in what our employees have to say about their work experience
with the company/ Please complete this form.

1. What did you like most about your job?

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
2. What did you like least about your job?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

3. How did you feel about the pay and benefits?

EX
CELLEN
T

Rate of pay for your job

Paid holidays
Paid Vacations
Retirement Plan
Medical Coverage for self
Medical coverage for dependents
Life insurance
Sick Leave

G
OOD

FA

IR

P
OOR

Opportunity to use your abilities

Sli
ery

N
ghtly

Sa eutral
atisfie
tisfied
d

Ve
Slig
ry
htly

Dis

Dis
satisfie
satisfied
d

Recognition for the work you did

Your supervisors management

method
The opportunity to talk with your
supervisor
The information you received on
policies, programs, projects, and
problems
The information you received on
departmental structure

Promotion policies and practices

Discipline policies and practices

Job transfer policies and practices

Overtime policies and practices

Performances review policies and

practices

Physical working condition

4. How did you feel about the following :

COMMENTS :
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
__________________________________________

5. a) If you are taking another job, what kind of work will you be doing?
______________________________________________________________________________________
______________________________________________________________________________________

______________________________________________________________________________________
b) What has your new place of employment offered you that is more attractive than
your present job?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

6. Could the company have made any improvements that might have influenced you to
stay on the job?

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Other remarks (optional) :

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________

________________________________
________________________________
Employees Signature
Date