EXIT INTERVIEW FORM
Name Institute / Department
Joining Date Designation
Resignation Date Employee Code
A. Please describe the primary reason(s) you are leaving your current position.
B. Did dissatisfaction with any of the following factors influence your decision to leave? YES NO
Type of work
Working conditions (setting, schedule, travel, flexibility)
Salary
Supervisor
Location
C. Please rate the following aspects of the job you are vacating. 1 3 5
2 4
Use the 1 – 5 scale below. Poor Average Excellent
o Type of work performed
o Fairness of workload
o Salary
o Working conditions
o Tools and equipment provided
o Supervision received
o Level of input in decisions that affected you
D. Please rate the following aspects of the organization overall. 1
2
3
4
5
Use the 1 – 5 scale below. Poor Average Excellent
o Training and career development opportunities
o Employee morale
o Fair treatment of employees
o Support of work-life balance
o Cooperation and support from co-workers
o Communication between management and employees
o Performance and development planning and evaluation
o Concern with quality and excellence
o Administrative polices/procedures
E. Please rate your supervisor on the following factors. 1 2 3 4 5
Use the 1 – 5 scale below. Never Seldom Often Usually Always
o Gave usable performance feedback
o Provided appropriate and challenging assignments
o Clearly communicated expectations
o Treated you fairly and respectfully
o Coached, trained, & developed you
HR/EI/Rev.03-15 v01 Thank you for your candid comments. All responses will be kept confidential 1
o Encouraged teamwork & cooperation
o Resolved concerns promptly & also listened to suggestions &
feedback
o Supported work-life balance
o Recognized the accomplishments
F. If you accepted another job, please complete the following:
Name of new employer :
Company Name :
Title of position :
Nature of work of position :
Salary of position :
What the new position and/or organization offers that we do not. :
What are your suggestions or improvements to Management?
Any other comments / suggestions?
What could have been done differently that would have convinced you to stay?
Human Resource Department
Interviewer Name: ____________________________________ Position :______________________________________________
Date : ____________________________________________ Signed: _______________________________________________
HR/EI/Rev.03-15 v01 Thank you for your candid comments. All responses will be kept confidential 2
