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? *

2. Opportunity for Advancement

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

1. Wage and Benefits

3. How would you rate the following?

Performance Reviews

C. Fair

Comments

Opportunity for Advancement

C. Fair

Comments

Training Received

C. Fair

Comments

Company Policies and Practices

C. Fair

Comments

Responsibilities

B. Good

Comments

Hours

B. Good

Comments

Support by Management

C. Fair

Comments

Work Load

C. Fair

Comments

Salary

B. Good

Comments

Benefits

D. Poor

Comments

Are there any additional benefits you would like to receive?

4. Did your Supervisor:

Demonstrate fair and equal treatment?

A. Yes

Comments

Provide recognition on the job?

B. No

Comments

Keep employees well informed?

B. No

Comments

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

A. Yes

Comments

Encourage feedback?

B. No

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?

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

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 2023-09-30

Deny Re-take Approve

Exit Interview

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