Exit Interview Form
As you prepare to leave our practice, you have a unique perspective on the strengths and weaknesses of our organization. The information you furnish is used as a means to identify issues regarding our working environment. We appreciate your honesty and cooperation and very much value your opinion. All responses are confidential.
Name ______Position ______
Start Date ______Last Day Worked ______
Reasons for leaving
Please indicate below your reason(s) for leaving. Circle each reason and rank by placing a #1 in the blank space to the left of the description, then a #2, and so on. Please indicate all factors that contributed to your decision.
(1)Return to school(10) Dissatisfied with work
(2)Dissatisfied with office atmosphere(11) Personal illness
(3)Illness in the family(12) Better salary
(4)Lack of childcare(13) Conflict with supervisor
(5)Dissatisfied with work space(14) Conflict with co-workers
(6)Career advancement/change(15) Safety
(7)Transportation problems(16) Retirement
(8)Found position at another organization(17) Other (explain) ______
(9)Dissatisfied with hours ______
Have you accepted another position? Yes No
If yes, what position?
At what organization?
Assessment of Facial Plastic Surgery Associates
1)What attracted you to our practice?
2)Overall, do you consider our policies fair?
3)What are the strengths of the practice?
4)What are the weaknesses of the practice?
Assessment of Job Content
1)How would you describe your workload? (check one)
too light light fair heavy too much
2)Was the training offered when you started sufficient? Yes No (please comment)
3) Was the ongoing training and education appropriate and up to date? Yes No
If not, what could have been provided to help fully develop and use your skills?
4) Do you feel you were recognized for you skills and accomplishments? Yes No
(please comment)
5) Were relationships with co-workers acceptable? Yes No (please comment)
6) Do you feel you were kept reasonably well informed regarding changes that affected your . work? Yes No (please comment)
Assessment of Supervision
1) Did the supervisor adequately communicate with staff members? Yes No (please comment)
2) Was the supervisor responsive to employees and suggestions? Yes No (please comment)
3)Did your supervisor’s management style have any effect on your decision to leave?
Yes No (please comment)
4) Was communication between you and your supervisor effective? Yes No (please comment)
Employee Benefits
1)Overall, how would you rank our benefits package?
Excellent Good Fair Poor No Opinion Was not eligible for benefits
2) Specifically, are there benefits you would like to have seen changed? Yes No (please comment)
Survey completed: Face to Face Via Mail
Date received ______Interviewer ______
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2000 KarenZupko & Associates, Inc.
625 North Michigan Avenue, #702, Chicago, IL60611
P: 312-642-5616 F: 312-642-5571