Form View - Dental Health Services Portal

Exit Interview

Please take a moment and complete the following questionnaire. We regret losing an employee and hope that through this questionnaire we can identify problem areas and rectify undesirable situations. This form will not become a part of your personnel file, and will not affect your rehire status. Your cooperation is appreciated.

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First Name *

Last Name

Phone Number *

1. Reason for leaving? *

1. Other Position
12. Hours

2. If you are leaving for a new position what makes it more attractive than the one you are leaving? *

1. Wage and Benefits
2. Opportunities/Advancement
4. Hours
7. Flexibility

3. How would you rate the following?

Performance Reviews

C. Fair

Comments

Opportunity for Advancement

B. Good

Comments

Training Received

B. Good

Comments

Company Policies and Practices

C. Fair

Comments

Responsibilities

B. Good

Comments

Hours

D. Poor

Comments

Support by Management

B. Good

Comments

Work Load

D. Poor

Comments

Salary

B. Good

Comments

Benefits

C. Fair

Comments

Are there any additional benefits you would like to receive?

Discounts

4. Did your Supervisor:

Demonstrate fair and equal treatment?

A. Yes

Comments

Provide recognition on the job?

A. Yes

Comments

Keep employees well informed?

A. Yes

Comments

Make themselves available for discussion of any problems or potential problems?

A. Yes

Comments

Encourage feedback?

A. Yes

Comments

Explain the position and responsibilities of the job you held?

A. Yes

Comments

5. What is your opinion of the job you had with us?

I loved the training I did for the job. They provided great feedback but just the hours & school locations.

6. What were some of the frustrations you experienced in the performance and execution of job responsibilities?

Some of the frustrations I experienced in the performance and execution of job responsibilities were when a student doesn’t come to school, I don’t work and it’s a 75% chance that I will have to decline second location due it being too far and not the areas I provided .

7. Would you be willing to stay with our Company under a more satisfactory arrangement?

B. No

What changes would be required?

Overall Comments

Form Status: Approve

Draw Signature

Date 2024-03-10

Deny Re-take Approve

Exit Interview

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