Pulaski County Employee Exit Interview Form

Pulaski County Employee Exit Interview Form

(Confidential)

Confidential

Date: ______

Employee Name: ______Department: ______

Supervisor: ______Termination Date: ______

Position Held: ______Salary: ______

Part 1 – Reasons for Leaving Employment:

RESIGNATION (please check all that apply, circle primary reason and explain):

_____ Took another position _____ Dissatisfaction with supervisor/management

_____ Home/Family needs _____ Dissatisfaction with type of work

_____ Relocation to another area _____ Dissatisfaction with working conditions

_____ Poor health-physical problems _____ Dissatisfaction with salary

_____ To attend school _____ Other

Explanation: ______

______

LAID OFF RETIREMENT

_____ Lack of work _____ Voluntary retirement

_____ Position eliminated _____ Compulsory retirement

_____ Financial

DISCHARGED

_____ Violation of policies _____ Tardiness/Excessive Absenteeism

_____ Unsatisfactory work performance _____ Dishonesty/Stealing

_____ Insubordination _____ Controlled substance abuse

_____ Other (specify) ______

______

Part II: Comments/Suggestions for Improvement:

What did you enjoy most about your job? ______

What did you like least about your job? ______

How did you feel about the benefits that were offered? ______

Excellent Good Fair Poor

Rate of pay ______

Paid holidays ______

Annual Leave/Sick Leave Accrual ______

Retirement plan ______

Medical/Dental coverage ______

Life insurance ______

Pulaski County Employee Exit Interview (Page 2)

Part II: Comments/Suggestions for Improvement (Continued):

How do you feel about the following:

Very Slightly Slightly Very

Satisfied Satisfied Neutral Dissatisfied Dissatisfied

Opportunity to use your abilities ______

Recognition of the work you did ______

Training you received ______

Supervisor’s management method ______

Communication with supervisor ______

Information on policies ______

Discipline policies ______

Discipline practices ______

Time off policies ______

Time off practices ______

Performance reviews ______

If you are taking another job, what type of work will you be doing? ______

______

What has your new place of employment offered you that is more attractive than your present job? ______

______

Could Pulaski County have made any improvements that might have influenced you to stay on the job?

______

Other Comments: ______

______

______

Pulaski County Employee Exit Interview (Page 3)

Part III – Payroll Information:

Print employee deduction screen to determine deductions being taken:

Leave Payout: Sick Leave _____ Annual Leave _____ Comp. Time _____

Final Payout: Check _____ Direct Deposit _____

Forwarding address: ______

Employer & Employee Paid Deductions:

Single Deduction Double Deduction Term. Date

_____ VRS ______

_____ Health Insurance ______

_____ Dental Insurance ______

Employee Paid Deductions:

Term Date Term Date

Christmas Club ______Washington National ______

AFLAC ______Colonial ______

TransAmerica ______Virginia Credit Union ______

YMCA ______United Way ______

Nationwide Deferred Comp ______Optional Life ______

Flexible Spending Account (FSA) ______

Other:

_____ Uniforms returned

_____ Return of keys

_____ Health Savings Account – Employee keeps what is remaining in account

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Employer Use Only:

Term Date

Termed Aetna Insurance ______

Termed Delta Dental ______

Termed Eyemed ______

COBRA Benefits ______(Date of continuing coverage) Term ______

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______

Interviewers Signature Title Date

______

Employee Signature Employee (Please Print) Date

Copy provided to employee: _____