[Company name]
Exit Interview
Your opinion is important to us.

Name: _________________________________    Supervisor: ______________________________
(optional)    (optional)
Department:  ___________________________    Position: ________________________________

1.    Why are you leaving the company?    Personal
reason    Medical
benefits    Quality of supervision    Work
environment
2.    Please explain your reason(s) for leaving in more detail.
3.    What suggestions for improvement do you have for us?
4.    If we implemented those suggestions, would you return to work here?    Yes    No
5.    Would you recommend this company to your friends as a good place to work?    Yes    No
    In this section, please rate the following statements:    Strongly
agree    Somewhat
agree    Somewhat
disagree    Strongly
disagree
6.    I believe that I was treated like a valuable member of the company .    1    2    3    4
7.    My immediate supervisor let me know when I was doing a good job.    1    2    3    4
8.    I felt free to suggest to my supervisor changes that would improve my department.    1    2    3    4
9.    My job duties and responsibilities were clearly defined.    1    2    3    4
10.    I received the proper training in order to perform my job effectively.    1    2    3    4
11.    Employee problems and complaints were resolved fairly and promptly in my department.    1    2    3    4
12.    If I had questions or concerns, I felt comfortable speaking with:
    My immediate supervisor    1    2    3    4
    Upper management    1    2    3    4
    Human resources    1    2    3    4
13.    I was kept well informed about the company, its policies and procedures, and other important information.    1    2    3    4
14.    I felt that the company provided me with job security.    1    2    3    4
15.    Please rate the benefits that you received at the company (keeping in mind the benefits offered by other companies that you have worked for):
    In this section, please rate the following items:    Excellent    Good    Fair    Poor
    Medical    1    2    3    4
    Dental    1    2    3    4
    Vision    1    2    3    4
    Paid time off    1    2    3    4
    401(k) plan    1    2    3    4
    Please list any additional benefits that you would have wanted the company to offer:
Additional comments and suggestions are encouraged.
Use the space provided below for any additional comments.