TRI-STATE CENTERS FOR SIGHT, INC. Human Resource
TERMINATION/RESIGNATION: EMPLOYEE EXIT INTERVIEW
The following questions listed are designed to obtain your open response about your work experience during your employment at Tristate Centers for Sight. We value this information to learn what we might do better or differently, therefore your input is important.
We will maintain your response in strict confidence. You will have an opportunity to expand on these comments during your exit interview.
You may share this information You may not share this information
Employee Information
Employee Name: Date:
Date of Employment: from to
Date of Termination/Resignation:
Division: Manager Name:
What was your primary reason for leaving our practice?
Please rate your level of satisfaction with the following:
Very Reasonably Somewhat
Satisfied Satisfied Satisfied Dissatisfied Dissatisfied
Compensation & Benefits
1. Overall employee benefit package
2. How satisfied were you with our
practice’s compensation plan?
3. How satisfied were you with the
following benefits?
Medical Insurance
Dental Insurance
401K/Pension
Profit Sharing
4. On the job training
Work Environment
For the following items listed on the next page please indicate which level of agreement or disagreement:
Strongly Somewhat Strongly
Agree Agree Agree Disagree Disagree
5. My manager was open to discussing
work-related problems.
6. My performance objectives were clear.
7. My manager communicated clearly and
efficiently.
8. My manager encouraged teamwork
9. I was provided the appropriate tools
for my job.
10. My assessment/evaluation of my job
performance was fair and honest.
11. My workload was manageable
12. My management addressed conflict
appropriately.
Values and Objectives
13. I am proud to have worked at
Tristate Centers for Sight
14. Management and Physicians
recognize good performance.
15. Tristate Centers for Sight is well
managed.
16. Unethical behavior is never tolerated
17. The practice has high values, and is
future oriented for patients and
employees.
18. My job provided opportunities to
take initiative.
Miscellaneous
19. I would recommend Tristate Centers for Sight to others as a place to work.
Yes No Possibly Unlikely
20. Could we have done anything to prevent you from leaving?
Yes No Possibly Unlikely
Please list any other comments or suggestions you may have below:
Thank you for taking time to complete this form for your exit interview.