Exit Interview Survey Template

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EXIT INTERVIEW SURVEY
Instructions: The exit interview is an opportunity to obtain valuable information about
perceptions, frustrations and areas in need of improvement. The Exit Interview Survey is
designed to gather information in a consistent non-threatening manner. Although written
in survey format, each department is encouraged to identify a neutral third party to meet
one on one with the employee and gather information orally. The exit interview is
voluntary but strongly encouraged.
After the information is gathered the department should complete the lower section of the
form and submit to the Employee Relations Office (Room 213 Scovell Hall, 0064), Human
Resource Services. The form does not require a name and does not become part of any
personnel file. The focus is not on “who said what” rather to assist in identifying factors
which contribute to dissatisfaction and turnover.
1. Describe the circumstances that have lead you to resign or separate:
2. Mark any of the following that are reason(s) for your resignation or separation:
Check mark all that apply
Ο Supervisor
Ο Work hours
Ο Job security
Ο Stress
Ο Staffing level
Ο Grade of position
Ο Benefits
Ο Overtime requirements
Ο Lack of information
Ο Pay
Ο Potential layoff
Ο Training and development
Ο Job responsibility
Ο Equipment and supplies
Ο Co-workers
Ο Promotional
Ο Management above
Ο Physical working conditions
opportunities
supervisor
3. If “Supervisor” or “Management above supervisor” is check marked above, complete
the following questions:
Supervisor
Above
How well does your
supervisor or management above
supervisor…
Ineffective
Effective
Ineffective
Effective
Ο
Ο
Ο
Ο
A. Recognize problems needing
improvement
Ο
Ο
Ο
Ο
B. Understand employees' skills,
abilities and commitment
Ο
Ο
Ο
Ο
C. Organize and coordinate
department activities to solve
problems
Ο
Ο
Ο
Ο
D. Recognize the department's role in
addressing University needs
Ο
Ο
Ο
Ο
E. Select plans to address the cause of
problems
Ο
Ο
Ο
Ο
F. Recognize and act on
opportunities to solve problems
Ο
Ο
Ο
Ο
G. Maintain an environment of open
communication
EXIT INTERVIEW SURVEY
Instructions: The exit interview is an opportunity to obtain valuable information about
perceptions, frustrations and areas in need of improvement. The Exit Interview Survey is
designed to gather information in a consistent non-threatening manner. Although written
in survey format, each department is encouraged to identify a neutral third party to meet
one on one with the employee and gather information orally. The exit interview is
voluntary but strongly encouraged.
After the information is gathered the department should complete the lower section of the
form and submit to the Employee Relations Office (Room 213 Scovell Hall, 0064), Human
Resource Services. The form does not require a name and does not become part of any
personnel file. The focus is not on “who said what” rather to assist in identifying factors
which contribute to dissatisfaction and turnover.
1. Describe the circumstances that have lead you to resign or separate:
2. Mark any of the following that are reason(s) for your resignation or separation:
Check mark all that apply
Ο Supervisor
Ο Work hours
Ο Job security
Ο Stress
Ο Staffing level
Ο Grade of position
Ο Benefits
Ο Overtime requirements
Ο Lack of information
Ο Pay
Ο Potential layoff
Ο Training and development
Ο Job responsibility
Ο Equipment and supplies
Ο Co-workers
Ο Promotional
Ο Management above
Ο Physical working conditions
opportunities
supervisor
3. If “Supervisor” or “Management above supervisor” is check marked above, complete
the following questions:
Supervisor
Above
How well does your
supervisor or management above
supervisor…
Ineffective
Effective
Ineffective
Effective
Ο
Ο
Ο
Ο
A. Recognize problems needing
improvement
Ο
Ο
Ο
Ο
B. Understand employees' skills,
abilities and commitment
Ο
Ο
Ο
Ο
C. Organize and coordinate
department activities to solve
problems
Ο
Ο
Ο
Ο
D. Recognize the department's role in
addressing University needs
Ο
Ο
Ο
Ο
E. Select plans to address the cause of
problems
Ο
Ο
Ο
Ο
F. Recognize and act on
opportunities to solve problems
Ο
Ο
Ο
Ο
G. Maintain an environment of open
communication
EXIT INTERVIEW SURVEY
Ο
Ο
Ο
Ο
H. Clearly communicate the purpose
of plans or projects
Ο
Ο
Ο
Ο
I. Establish an environment of open
communication
Ο
Ο
Ο
Ο
J. Clearly communicate the purpose
of plans or projects
Ο
Ο
Ο
Ο
K. Understand and accommodate
your needs
4. If “Benefits” is check marked (in #2 above), mark the specific benefits:
Ο Holidays
Ο Health insurance options
Ο Dental plan options
Ο Vacation days
Ο Retirement contribution
Ο Dental plan costs
Ο Sick leave
Ο Retirement fund options
Ο Long term disability
Ο Health insurance costs
Ο Life insurance
5. List the reasons you check marked (in #2 above) and provide a reason for your
dissatisfaction:
Reason
Reason for Dissatisfaction
Use reverse for additional space
6. List the reasons you check marked (in #2 above) and provide a recommendation to
solve the problem:
Reason
Recommendation
Use reverse for additional space
7. If you had the opportunity to return to employment in your department in the future
what are the top three (3) things that will need to change.
8. Please make any additional comments:
To be completed by Department:
Department Name:
Position Title:
Length of
Length of Department
University Service:
Service:
Supervisors Name:
Route this page to Business Officer or Technical Support Area
Employee Name: _____________________________________________________
UK ID:
_____________________________________________________
Department:
_____________________________________________________
Phone Number: _____________________________________________________
Check List of Services and Security:
Yes
No
Business Office/Administrative Staff:
0
0
Keys Returned:
Specify Phone Access changes required: ______________________________________
_______________________________________________________________________
Technical Support Office:
0
0
Electronic Home Equipment Returned:
0
0
Security Revoked:
(When) Account disable date: ____________________
(What) Electronic Security Revoked: _______________________________________
_______________________________________
(HRS/FRS, Beta 93, client/server software, shared file server, etc.)
If the employee has files on their office computer or shared file server, who should
receive access to these files? __________________________________

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