We  would appreciate your candid answers to the following questions. Your individual responses are treated as confidential and will not become part of your personnel file. Results will be aggregated with responses from other employees before being disclosed to [Company Name] leadership.

We believe that your feedback is of vital importance and will assist [Company Name] in analyzing our employee retention and turnover. Thank you for your cooperation!  

 

Name Hire Date Department Separation Date Position Manager

   

What prompted you to seek alternative employment? (check all that apply)

☐ Type of work                                        ☐ Compensation

☐ Lack of recognition                              ☐ Relationship with supervisor

☐ Working conditions                              ☐ Family circumstances

☐ Company culture                                  ☐ Career advancement opportunity

☐ Business direction                                ☐ Other: ________________________

 

Please rate your supervisor below using a scale of 1-5, with 5 being strongly agree and 1 being strongly disagree. Please select one response for each statement.   

Supervisor/Manager54321N/ADemonstrated fair and equal treatment° ° ° ° ° ° Provided recognition on the job° ° ° ° ° ° Developed cooperation and teamwork° ° ° ° ° ° Encouraged/listened to suggestions° ° ° ° ° ° Resolved complaints and problems° ° ° ° ° ° Followed policies and practices° ° ° ° ° ° Communicated well° ° ° ° ° ° Comments or suggestions for improvement: ​ ​ ​ ​ ​ ​

Please rate your employment at [Company Name] below using a scale of 1-5, with 5 being highly satisfied and 1 being highly dissatisfied. Please select one response for each statement. 

Please rate the compensation and benefits at [Company Name] below using a scale of 1-5, with 5 being highly satisfied and 1 being highly dissatisfied. Please select one response for each statement. 

What did you like most about your job and/or this company? _____________________________________________________________________

_____________________________________________________________________

 

What did you like least about your job and/or this company? _____________________________________________________________________

_____________________________________________________________________

 

Additional comments: _____________________________________________________________________

_____________________________________________________________________

 

Would you recommend this company to a friend as a place to work? ☐ Yes, without reservations         ☐ Yes, with reservations        ☐ No

If no, why not? __________________________________________________________