Fillable CONFIDENTIAL EMPLOYEE EXIT INTERVIEW FORM (Southern University at Shreveport)

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CONFIDENTIAL EMPLOYEE EXIT INTERVIEW FORM (Southern University at Shreveport)

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08/24/10
Page 1 of 3
CONFIDENTIAL
EMPLOYEE EXIT INTERVIEW FORM
Date:
Name:
Security Social Number:
Location/Department:
Supervisor:
Hire Date:
Termination Date:
Starting Position:
Ending Position:
Starting Salary:
Ending Salary:
PART l: REASONS FOR LEAVING
More than one reason may be given if appropriate; if so, circle primary reason.
RESIGNATION
Took another position
Dissatisfaction with salary
Pregnancy/home/family needs
Dissatisfaction with type of work
Poor health/physical disability
Dissatisfaction with supervisor
Relocation to another city
Dissatisfaction with co-workers
Travel difficulties
Dissatisfaction with working conditions
To attend school
Dissatisfaction with benefits
Other (specify)
LAID OFF RETIREMENT
Lack of work
Voluntary retirement
Abolition of position
Disability retirement
Lack of funds
Regular retirement
Other (specify)
Plans After Leaving
08/24/10
Page 2 of 3
PART ll: COMMENTS/SUGGESTIONS FOR IMPROVEMENT
We are interested in what our employees have to say about their work experience with the University. 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?
Excellent
Good
Fair
Poor
Rate of pay for your job
Paid holidays
Paid vacations
Retirement plan
Medical coverage for self
Medical coverage for dependents
Life insurance
Sick leave
4. How did you feel about the following:
Very
Satisfied
Slightly
Satisfied
Neutral
Slightly
Dissatisfied
Very
Dissatisfied
Opportunity to use your abilities
Recognition for the work you did
Training you received
Your supervisor’s management
methods
The opportunity to talk with your
supervisor
The information you received on
policies, programs, projects and
problems
The information you received on
departmental structure
Promotion policies and practices
Discipline policies and practices
Job transfer policies and practices
Overtime policies and practices
Performance review policies and
practices
Physical working conditions
08/24/10
Page 3 of 3
COMMENTS:
5. 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 the University have made any improvements that might have influenced you to stay on the job?
Other remarks (optional):
_____________________________________________________ __________________________
Employee’s Signature Date
DO NOT WRITE BELOW THIS LINE. 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 Signature Date
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CONFIDENTIAL EMPLOYEE EXIT INTERVIEW FORM (Southern University at Shreveport)

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Completed 26 July 2020

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