Exit Interview Survey

EXIT INTERVIEW QUESTIONNAIRE
(Sample)

Please take a few minutes to complete this questionnaire so <Company> can better understand your reasons for leaving. We use this information as feedback for our employee retention efforts. Your responses to this survey are returned directly to LOMA and aggregated with other responses so that your comments are completely confidential.

General Information

Department name:
Dept#
Supervisor's name:
Your <Company> job title:
Hire date:
Termination date:

Status

Exempt

Non-exempt/hourly

Sex:

Female

Male

How much did the following items factor into your decision to leave?

	Not at all	Small amount	Moderate amount	Large amount
Type of work (job content, duties, etc.)
Workload or work hours/schedule
Work environment (stress, frustrations, rules, etc.)
Pay
Group insurance or retirement benefits
	Not at all	Small amount	Moderate amount	Large amount
Other benefits (vacation, paid holidays, etc.)
Lack of advancement/promotion opportunity
Inadequate training and development
Unfair treatment by management
Lack of recognition/appreciation from management
	Not at all	Small amount	Moderate amount	Large amount
Problems with co-workers in your department
Problems with co-workers in other departments
Treatment from supervisor/problems with supervisor
Upper management's actions/decisions
Company reputation or performance record
	Not at all	Small amount	Moderate amount	Large amount
Relocation
Commuting distance
Family circumstances
Personal health
Return to school
Retirement
Other (Please describe):

Please explain any of the above items that you rated as large factors in your decision to leave, and give your main reason for leaving:

Please rate the following items about your job, co-workers, supervisor, and <Company>.

	Strongly Disagree	Somewhat Disagree	Neither Agree Nor Disagree	Somewhat Agree	Strongly Agree
The realities of my job matched what <Company> told me to expect when I was first hired.
My job was a good match with my skills, needs, and interests.
I had adequate advancement and promotion opportunities at <Company>.
My co-workers usually met my expectations for teamwork, effort, etc.
My supervisor clearly explained what was expected of me.
My supervisor recognized and appreciated my efforts.
My pay level and raises were fair in relation to my job performance and responsibilities.
If I ever returned to <Company>, I would be willing to work for the same boss again.
I would be willing to work for <Company> again in the future.

Please explain any of the above items to which you strongly disagreed:

What could have been done to prevent your leaving?

If you have accepted a new job, for what company will you be working?

In your opinion, what is it about your new job or employer that is better than the situation you had at <Company>?

If you have any other comments you would like to make, please enter them below:

Thank you very much for taking the time to complete this questionnaire. As indicated above, your responses are returned to LOMA and are completely confidential. However, if you have any questions, please contact <Company>'s HR department. We wish you the best of luck!

� 2006 LOMA (Life Office Management Association)