Exit Interview
NOTICE: Please supply the information requested below in order that we may evaluate
employment process. Information obtained from you will be treated in a confidential manner
and will be shared with your previous supervisor in summary form only.
SECTION I
(IF YOU DO NOT WISH TO COMPLETE THIS SECTION, PLEASE COMPLETE SECTION II)
Job Title: ______________________________ Current Date: ___________________
REASON(S) FOR RESIGNATION/TRANSFER
Inadequate salary/contract fee Dislike Supervisor/ Company
Other employment Disliked working holidays & weekends
Relocation Disliked working conditions
No adjusted work schedule Health reasons
Changes in personal life Family demands
Career change Returned to school
Advanced Opportunities Early Retirement
Conflict with agency personnel Disliked leave policy
Job demands/requirements Other (please specify) _______________________
What was your opinion of the following? (Good, Fair, Poor)
Cooperation with supervisor ______________
Orientation to policies and procedures ______________
Adequacy of training ______________
Workload ______________
Your contract fee ______________
Physical working conditions ______________
When you first reported to work, were you introduced to your co-workers? Yes No
Were your duties and responsibilities explained clearly? Yes No
Did your supervisor handle, in a manner satisfactory to you, problems Yes No
which occurred in your work unit?
Did you always receive the help you needed in the performance of your Yes No
duties?
If yes, from whom? Supervisor Co-worker Others
Was your immediate supervisor objective and fair in treatment of Yes No
employees?
If no, please explain: ___________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Were your performance ratings discussed with you? Yes No
Did your performance ratings give you a good idea of how well you Yes No
were performing your job duties?
Describe your work as an employee/ contractor of Jireh Counseling, Inc. (please check all that
apply):
Challenging Tedious Difficult
Exciting Unbearable Overwhelming
Boring Okay Easy
Fun Interesting Other ________
Rewarding Educational
What recommendations would you make for improving your work experiences with the agency?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Please make any other comments you wish about your employment with the Jireh Inc. _______
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Your Signature (optional): _________________________________Date: ____________
SECTION II
(DO NOT COMPLETE THIS SECTION IF YOU HAVE COMPLETED SECTION I ABOVE)
I have been offered an opportunity to complete Section I of “Exit Interview Information” and
choose not to participate.
Your Signature (optional): _________________________________ Date: ________________
Please return completed form through one of the following ways:
By mail: CEO By Fax: 404.761.0720
Jireh Counseling and Consulting Service, Inc. By Email: provider@jirehcounseling.com
5538-M Old National Hwy, Suite 350.
College Park GA 30349
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For JIREH use only
Returned Property Checklist:
First Aid Kit Yes No N/A Signature: ______________
ID Badge Yes No N/A Signature: ______________
Employee/Contractor Handbook Yes No N/A Signature: ____________
Other, if applicable:
___________________ Yes No N/A Signature: ______________
___________________ Yes No N/A Signature: ______________
___________________ Yes No N/A Signature: ______________
All Passwords were terminated Signature: ______________
