Exit Interview Form Employee Exit Interview Form Date MM slash DD slash YYYY Name Location/Department Supervisor Hire Date Termination Date Starting Position Ending Position Starting Salary Ending Salary PART 1: REASONS FOR LEAVING More than one reason may be given if appropriate; if so, circle primary reason. RESIGNATION Took another position Pregnancy/home/family needs Poor health/physical disability Relocation to another city Travel difficulties To attend school Other (specify) Dissatisfaction with salary Dissatisfaction with type of work Dissatisfaction with supervisor Dissatisfaction with co-worker Dissatisfaction with working conditions Dissatisfaction with benefits LAID OFF Lack of work Abolition of position Lack of funds Other (specify) RETIREMENT Voluntary retirement Disability retirement Regular retirement Plans After LeavingPART 2: COMMENTS/SUGGESTIONS FOR IMPROVEMENT We are interested in what our employees have to say about their work experience with Mitec. 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?Rate of pay for your job Poor Fair Good Excellent Rate of pay for your job Additional NotesPaid holidays Poor Fair Good Excellent Paid Holidays Additional NotesPaid vacations Poor Fair Good Excellent Paid Vacations Additional NotesRetirement plan Poor Fair Good Excellent Retirement plan Additional NotesMedical coverage for self Poor Fair Good Excellent Medical coverage for self Additional NotesMedical coverage for dependents Poor Fair Good Excellent Medical coverage for dependents Additional NotesLife insurance Poor Fair Good Excellent Life insurance Additional NotesSick leave Poor Fair Good Excellent Sick Leave Additional Notes4. How did you feel about the following:Opportunity to use your abilities Very Dissatisfied Slightly Dissatisfied Neutral Slightly Satisfied Very Satisfied Opportunity to use your abilities Additional NotesRecognition for the work you did Very Dissatisfied Slightly Dissatisfied Neutral Slightly Satisfied Very Satisfied Recognition for the work you did Additional NotesTraining you received Very Dissatisfied Slightly Dissatisfied Neutral Slightly Satisfied Very Satisfied Training you received Additional NotesYour supervisor’s management methods Very Dissatisfied Slightly Dissatisfied Neutral Slightly Satisfied Very Satisfied Your supervisor’s management methods Additional NotesThe opportunity to talk with your supervisor Very Dissatisfied Slightly Dissatisfied Neutral Slightly Satisfied Very Satisfied The opportunity to talk with your supervisor Additional NotesThe information you received on policies, programs, projects and problems Very Dissatisfied Slightly Dissatisfied Neutral Slightly Satisfied Very Satisfied The information you received on policies, programs, projects and problems Additional NotesThe information you received on departmental structure Very Dissatisfied Slightly Dissatisfied Neutral Slightly Satisfied Very Satisfied The information you received on departmental structure Additional NotesPromotion policies and practices Very Dissatisfied Slightly Dissatisfied Neutral Slightly Satisfied Very Satisfied Promotion policies and practices Additional NotesDiscipline policies and practices Very Dissatisfied Slightly Dissatisfied Neutral Slightly Satisfied Very Satisfied Discipline policies and practices Additional NotesJob transfer policies and practices Very Dissatisfied Slightly Dissatisfied Neutral Slightly Satisfied Very Satisfied Job transfer policies and practices Additional NotesOvertime policies and practices Very Dissatisfied Slightly Dissatisfied Neutral Slightly Satisfied Very Satisfied Overtime policies and practices Additional NotesPerformance review policies and practices Very Dissatisfied Slightly Dissatisfied Neutral Slightly Satisfied Very Satisfied Performance review policies and practices Additional NotesPhysical working conditions Very Dissatisfied Slightly Dissatisfied Neutral Slightly Satisfied Very Satisfied Physical working conditions Additional NotesCOMMENTS5. 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 Mitec have made any improvements that might have influenced you to stay on the job?Other remarks (optional):Employee's SignatureDate MM slash DD slash YYYY OFFICE USE ONLY. Discussed with employee Right to file for unemployment benefits Conversion of benefits If retiring, state option for payment of unused leave Interviewer's SignatureDate MM slash DD slash YYYY
