Form DHR-30 "Exit Questionnaire" - Illinois

What Is Form DHR-30?

This is a legal form that was released by the Illinois Department of Human Rights - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2012;
  • The latest edition provided by the Illinois Department of Human Rights;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DHR-30 by clicking the link below or browse more documents and templates provided by the Illinois Department of Human Rights.

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Download Form DHR-30 "Exit Questionnaire" - Illinois

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EXAMPLE
EXIT QUESTIONNAIRE
Instructions: This questionnaire will be provided to all employees at the time of their separation from the agency whether
voluntary or involuntary. The completion of this questionnaire shall be at the employee’s option. Please send the
completed form in an envelope to the Equal Employment Opportunity Officer. The Equal Employment Opportunity Officer
shall maintain a separate file of all forms for possible review by the Department of Human Rights.
Name _____________________________________________
Sex: Male_____
Female______
Age: _____
Disability: Yes_____
No_____
Race_________________________________
Hispanic: Yes____ No____
Date of Employment __________________________________
Separation Date____________________________
Position Title _________________________________________________________
Starting Salary ___________________________________Current Salary ____________________________________
Who was your immediate supervisor? _________________________________________________________________
Reason for leaving: _______________________________________________________________________________
________________________________________________________________________________________________
Were you terminated while still in your probationary period? If so, what could your agency have done to ensure you
successfully met your probationary period resulting in certification?
________________________________________________________________________________________________
________________________________________________________________________________________________
Would you want to work here again?
Yes ________
No _______
Explain: ________________________________________________________________________________________
________________________________________________________________________________________________
Same Position? Yes ____ No _____
Explain: ________________________________________________________
________________________________________________________________________________________________
Same Supervisor? Yes ____ No_____ Explain: _______________________________________________________
________________________________________________________________________________________________
Do you feel the working conditions were satisfactory?
Yes _____ No _____ Explain: ______________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
EXAMPLE
EXIT QUESTIONNAIRE
Instructions: This questionnaire will be provided to all employees at the time of their separation from the agency whether
voluntary or involuntary. The completion of this questionnaire shall be at the employee’s option. Please send the
completed form in an envelope to the Equal Employment Opportunity Officer. The Equal Employment Opportunity Officer
shall maintain a separate file of all forms for possible review by the Department of Human Rights.
Name _____________________________________________
Sex: Male_____
Female______
Age: _____
Disability: Yes_____
No_____
Race_________________________________
Hispanic: Yes____ No____
Date of Employment __________________________________
Separation Date____________________________
Position Title _________________________________________________________
Starting Salary ___________________________________Current Salary ____________________________________
Who was your immediate supervisor? _________________________________________________________________
Reason for leaving: _______________________________________________________________________________
________________________________________________________________________________________________
Were you terminated while still in your probationary period? If so, what could your agency have done to ensure you
successfully met your probationary period resulting in certification?
________________________________________________________________________________________________
________________________________________________________________________________________________
Would you want to work here again?
Yes ________
No _______
Explain: ________________________________________________________________________________________
________________________________________________________________________________________________
Same Position? Yes ____ No _____
Explain: ________________________________________________________
________________________________________________________________________________________________
Same Supervisor? Yes ____ No_____ Explain: _______________________________________________________
________________________________________________________________________________________________
Do you feel the working conditions were satisfactory?
Yes _____ No _____ Explain: ______________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Do you have any suggestions for improving employee morale? ______________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Were you satisfied with the pay you received for the work performed and with promotions? Yes______ No______
Explain: _________________________________________________________________________________________
________________________________________________________________________________________________
Did you receive bilingual pay? If so, do you feel it was an appropriate amount? ________________________________
________________________________________________________________________________________________
Were you satisfied with the supervision and were you trained properly?
Yes_____ No_____ Explain: _______________________________________________________________________
________________________________________________________________________________________________
Do you think management adequately recognized employee contributions? If not, what recommendations would you
make to improve this?
________________________________________________________________________________________________
________________________________________________________________________________________________
Did you receive any equal employment opportunity / affirmative action orientation? Yes_____ No_____
Explain: _________________________________________________________________________________________
________________________________________________________________________________________________
During your employment did you request an accommodation based on your disability? Yes____ No____ N/A____
If yes, please explain:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Did you personally experience any discrimination while working in your position?
Yes _____ No _____ Explain: ______________________________________________________________________
________________________________________________________________________________________________
Are you aware of instances where others have been discriminated against?
Yes _____ No_____ Explain: ___________________________________________________________________________________
___________________________________________________________________________________________________________
If you have answered “Yes” to the last two questions, have you discussed or given written notice of this discrimination to
your supervisor or EEO/AA Officer?
Yes _____ No ______ Explain: ______________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Additional comments / concerns: ______________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Employee Signature ________________________________________________________ Date ___________________________
DHR-30
Rev. May 2012
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