Exit Interview Questionnaire

We would appreciate you taking a few minutes to answer the following questions as honestly as possible. Your response will be treated
with the utmost confidentiality and will not become a part of your personnel file. The information you provide in section 1 and 10 is
required and is extremely important to assist the agency with employee retention strategies. Sections 2 through 9 are optional. Your
participation in the exit interview process is appreciated.

Date of Resignation: ______/______/______

Section 1 - Reason for Separation (REQUIRED)

Please describe the main reason(s) you are leaving your current positon?
☐ PER ☐ WOR ☐ PAY ☐ PRM ☐ CAR ☐ JOB ☐ PSE ☐ RTM
Personal Dissatisfied with Dissatisfied Dissatisfied with Career Job did not Private Sector Retirement
Reasons work Conditions with pay promotion or growth change meet Employment
opportunities expectations

Section 2 - Personal Factors Contributing to Resignation (OPTIONAL)

Please indicate the following factors that influenced your decision to leave (Check all that applies)
☐ Health Reasons ☐ Family Reasons ☐ Child Care
☐ Relocating ☐ Career Change ☐ Commute/Transportation
☐ Returning to School ☐ Marriage ☐ Other

Section 3 - Work/Job Factors Contributing to Resignation (OPTIONAL)

Please indicate the following factors that influenced your decisions to leave (Check all that applies)
☐ Dissatisfaction with type of work ☐ Dissatisfaction with workload
☐ Dissatisfaction with tools and equipment provided ☐ Dissatisfaction with working conditions
☐ Dissatisfaction with level of input in decision ☐ Dissatisfaction with training and development received
☐ Dissatisfaction with coworkers/teamwork ☐ Dissatisfaction with supervision received
☐ Dissatisfaction with working hours ☐ Dissatisfaction with promotional opportunities
☐ Dissatisfaction company policies ☐ Dissatisfaction with work location
☐ Dissatisfaction with lack of recognition ☐ Dissatisfaction with the lack of organization vision

Section 4 - Pay/Benefits Factors Contributing to Resignation (OPTIONAL)

Please indicate the following factors that influenced your decisions to leave (Check all that applies)
☐Salary ☐ Retirement benefits/Pension 401k
☐ Healthcare Options ☐ Flexible Benefits Options
☐ Healthcare cost ☐ Flexible Benefits Cost
☐ Leave Benefits ☐ Support of work-life balance

Section 5 - Overall Rating of Organization (OPTIONAL)

How would you rate the following aspect of the overall organization? (Use the scale 1 – Lowest and 5 – Highest)
1 2 3 4 5 1 2 3 4 5
Recruitment process New employee orientation
Training opportunities Career development opportunities
Employee morale Fair treatment of employee
Recognition for a job well done Communication between management and employee
Cooperation within the agency Interest and investment in employees
Performance management Process Concern with quality and excellence
Commitment to customer service Culture

Page 1 of 3
DOAS/HRA Exit Form 002
Created 6/1/15
Revised 6/13/2016
 Exit Interview Questionnaire
Section 6 - Overall Rating of your Supervisor (OPTIONAL)

How would you rate your supervisor on the following factors? (Use the scale 1-Never, 2-Seldom, 3-Often, 4-Usually, 5-Always)
1 2 3 4 5 1 2 3 4 5
Gave performance feedback regularly Recognized accomplishments
Clearly communicated expectations Treated me fairly and respectfully
Coached, trained and developed me Provided leadership
Encouraged teamwork and cooperation Resolved concerns in a timely manner
Listened to suggestions and feedback Kept employees informed
Supported work-life balance Provided appropriate and challenging
assignment

Section 7 - Overall rating of your Department/unit (OPTIONAL)

How would you rate the following aspect of the overall division/unit (Use the scale 1 – Lowest and 5 – Highest)
Rating Scale 1 2 3 4 5 Rating Scale 1 2 3 4 5
Opportunities for continuous learning Teamwork within the department
Communication within the department Opportunities for advancement within the
department
Morale within the department Working conditions within the department
Clear goals and expectations within the Department culture
department

Section 8 - Additional Questions (OPTIONAL)

What lead you to accept the position with our organization? Please explain:

Were your expectations of the job and this organization met? Please explain
☐ Yes ☐ No

Were your talents and skills used in completion of projects? Please explain:
☐ Yes ☐ No

Was your career path and future with our organization made clear If not, explain:
to you? ☐ Yes ☐ No

Were there any positive aspects about your job, manager, or the Please explain:
organization that caused you to say as long as you did? ☐ Yes ☐ No

Were there barriers to productivity in your job or work unit? Please explain:
☐ Yes ☐ No

What did you like most about your job? Please explain:

What did you like least about your job? Please explain:

What would you suggest to management to make our organization Please explain:
better?

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DOAS/HRA Exit Form 002
Created 6/1/15
Revised 6/13/2016
 Exit Interview Questionnaire
Section 9 Additional Comments (OPTIONAL)

Please provide any additional comments:

Section 10 – REQUIRED Information

Please provide the information below. This information will solely be used for additional data analysis.
Name: Agency Name:
Division/Unit: Length of Service:
Position Title: Manager Name:

Thank you for providing your feedback. Your participation is greatly appreciated.
Please submit the completed from to your Human Resources Office.

Page 3 of 3
DOAS/HRA Exit Form 002
Created 6/1/15
Revised 6/13/2016