Doc No.

: HR/FRM-124
Rev: 00
Feedback Form for Departing Employee’s Supervisor Date of Rev: March 31, 2015
Page: 1 of 1

CONFIDENTIAL
SUPERVISOR'S DETAILS DEPARTING EMPLOYEE'S DETAILS
SUPERVISOR'S NAME: EMPLOYEE NAME:
SUPERVISOR'S EMPLOYEE NO.: EMPLOYEE NO.:
GRADE: GRADE:
FUNCTION: FUNCTION:
BA / BSD: POTENTIAL STATUS:
EMPLOYEE'S SUPERVISOR SINCE: DATE OF RESIGNATION:
PART 1: How would you rate the departing employee on the following criterions?
Extremely Satisfied Dissatisfied Extremely Unacceptable
Satisfied Dissatisfied
1 Job Knowledge
2 Productivity
3 Work Quality
4 Technical Skills
5 Work Consistency
6 Teamwork
7 Attitude
8 Work Relations
9 Communication Skills
10 Initiatives/Creativity

PART 2: In your opinion, what could have stopped the departing employee from leaving the company? In case of more than one factor,
rank in order of their importance (1 being the most important one).
1 Better Salary
2 Overseas Opportunity
3 Job Rotation
4 Others (please specify)
PART 3: Supplemantry Questions

a. Is it a loss of a critical resource for the company? Please give reasons for your response
ð YES ð NO

b. Should the company reconsider to rehire the employee in future? Please give reasons for your response
ð YES ð NO

Human Resource Department

Date:________________________
Supervisor's Signature
Thank you for your response and valuable feedback.

HR Comments:

Name/Signature
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