NAME: |
| JOB TITLE: |
| START DATE WITH ORGANIZATION: |
| START DATE IN POSITION: |
| SEPARATION DATE: |
| OTHER POSITIONS HELD WITH ORGANIZATION: |
| 1. | Please describe the primary reason(s) you are leaving your current position. |
| 2. | Did dissatisfaction with any of the following factors influence your decision to leave? | YES | NO |
| Type of work | |||
| Working conditions (setting, schedule, travel, flexibility) | |||
| Pay | |||
| Supervisor | |||
| Location | |||
| Cost of living in area | |||
| Commute |
| 3. | Please rate the following aspects of the job you are vacating. Use the 1 – 5 scale below. | |||||
| 1 Poor | 2 | 3 Average | 4 | 5 Excellent | ||
| Type of work performed | ||||||
| Fairness of workload | ||||||
| Salary | ||||||
| Working conditions | ||||||
| Tools and equipment provided | ||||||
| Training received | ||||||
| Co-workers | ||||||
| Supervision received | ||||||
| Level of input in decisions that affected you | ||||||
4. | Please rate the following aspects of the organization overall. Use the 1 – 5 scale below. | |||||
| 1 Poor | 2 | 3 Average | 4 | 5 Excellent | ||
| Recruitment process | ||||||
| New employee orientation | ||||||
| Training opportunities | ||||||
| Career development opportunities | ||||||
| Employee morale | ||||||
| Fair treatment of employees | ||||||
| Recognition for a job well done | ||||||
| Support of work-life balance | ||||||
| Cooperation within the agency | ||||||
| Communication between management and employees | ||||||
| Performance and development planning and evaluation | ||||||
| Interest and investment in employees | ||||||
| Commitment to customer service | ||||||
| Concern with quality and excellence | ||||||
| Administrative polices/procedures | ||||||
| 5. | Please rate your supervisor on the following factors. Use the 1 – 5 scale below. | |||||
| 1 Never | 2 Seldom | 3 Often | 4 Usually | 5 Always | ||
| Gave usable performance feedback | ||||||
| Recognized accomplishments | ||||||
| Clearly communicated expectations | ||||||
| Treated you fairly and respectfully | ||||||
| Coached, trained, & developed you | ||||||
| Provided leadership | ||||||
| Encouraged teamwork & cooperation | ||||||
| Resolved concerns promptly | ||||||
| Listened to suggestions & feedback | ||||||
| Kept employees informed | ||||||
| Supported work-life balance | ||||||
| Provided appropriate & challenging assignments | ||||||
| 6. | If you accepted another job, please complete the following. | |
| Name of new employer | ||
| Location of position | ||
| Title of position | ||
| Nature of work of position | ||
| Salary of position | ||
| What the new position and/or organization offers that we do not. |
Additional questions:
- What do you consider to be the biggest challenge this organization now faces and needs to overcome?
- What would you suggest to management to make our organization a better place to work?
- Would you consider re-employment?
- What, if anything, could have been done to prevent you from leaving?
- Do you have any other comments or suggestions?
Amy N Kaplan 