Exit Interview

First Name

Last name

JOB TITLE:

Job Title

HIRE DATE *

HIRE DATE ×

TERMINATION DATE*

TERMINATION DATE ×

Primary Supervisor

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Additional Supervisor, if app.

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Why did you initially come to work for Elizabeth Layton Center (ELC)?*

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1. Why are you leaving ELC?*

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What things would have prevented your departure*

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What did you like most about working for ELC?

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What did you like least about working for ELC?

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What skills have you learned while working at ELC?

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Please rate your workload: Too heavy *

Too heavy

About right

Too light

Please list the name of your Primary Supervisor

Primary Supervisor Name

Please rate this Primary Supervisor in meeting your expectations for the following areas.*

	Excellent	Good	Fair	Poor	Unacceptable
	Excellent	Good	Fair	Poor	Unacceptable
Leadership
Communication
Management of Staff
Personal Effectiveness
Professional Knowledge
Customer Focus
Team Approach
Consistently Fair
Provided Recognition
Provided Performance Feedback
Followed ELC Policies

Additional comment about your Primary Supervisor

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Please list the name of your Department Director

Department Director Name

Please rate this Department Director in meeting your expectations for the following areas*

	Excellent	Good	Fair	Poor	Unacceptable
	Excellent	Good	Fair	Poor	Unacceptable
Leadership
Communication
Management of Staff
Personal Effectiveness
Professional Knowledge
Customer Focus
Team Approach
Consistently Fair
Provided Recognition
Provided Performance Feedback
Followed ELC Policies

Additional comment about your Department Director

Write here

Please rate the following based on your experience at ELC*

	Excellent	Good	Fair	Poor	Unacceptable
	Excellent	Good	Fair	Poor	Unacceptable
Cooperation within your program
Cooperation with other programs
Communication within your program
Job orientation and training
Job equipment provided
ELC’s performance review system
Career development/advancement
Physical working conditions
Safety
Team atmosphere
Learning opportunities

Additional comment

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Please rate the compensation and benefits package provided by ELC*

	Excellent	Good	Fair	Poor	Unacceptable
	Excellent	Good	Fair	Poor	Unacceptable
Salary/Wages
Paid Holidays
Medical Insurance
Dental Insurance
Optional Insurance (e.g. AFLACK)
Health Savings Account
Retirement Investment Plan
Educational Assistance
Life Insurance
Disability Benefits
Employee Assistance Plan
Work Hours/Schedule Flexibility

Additional comment

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Would you recommend ELC to others as a place to work?*

Yes, definitely

Yes, with reservations

Would you consider returning to ELC in the future?*

Yes

Maybe

CONFIDENTIALITY AGREEMENT:

Upon leaving ELC I will uphold the confidentiality of information obtained through the agency. I will not disclose the identity of any person receiving services or any information that might identify one as receiving services. I also agree to immediately terminate my professional relationship with any Clients/Families with whom I engaged as part of my work for ELC.

Please mark your primary reason(s) for leaving from the list below.

CONFIDENTIALITY AGREEMENT:

Thank You

Exit Interview

Please mark your primary reason(s) for leaving from the list below.

CONFIDENTIALITY AGREEMENT:

Thank You

Your form has been submitted