[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:
