CONFIDENTIAL

EMPLOYEE EXIT INTERVIEW FORM

Tanggal :
Date ------------------------------------------------------------------
Nama lengkap (sesuai ID) : No. ID :
Name ------------------------------------------------------------------ Security Social Number ------------------------------------------------------------------
Lokasi/Departemen Supervisor
: :
Location/Department ------------------------------------------------------------------ Supervisor ------------------------------------------------------------------
Tanggal Masuk Tanggal keluar
: :
Hire Date ------------------------------------------------------------------ Termination Date ------------------------------------------------------------------
Posisi Awal Posisi Terakhir
: :
Starting Position ------------------------------------------------------------------ Ending Position ------------------------------------------------------------------
Gaji Awal Gaji Terakhir
: :
Starting Salary ------------------------------------------------------------------ Ending Salary ------------------------------------------------------------------

BAG. l (ALASAN MENINGGALKAN PEKERJAAN)

PART l: REASONS FOR LEAVING
( Lebih dari satu alasan dapat diberikan kepada jika sesuai; jika demikian , silahkan diberi tanda (v) )
More than one reason may be given if appropriate; if so, circle primary reason

RESIGNATION (MENGUNDURKAN DIRI)

Mengambil posisi di tempat lain Tidak puas terhadap gaji/upah

Took another position Dissatisfaction with salary
Hamil/Menikah/ Keperluan keluarga Tidak puas terhadap jenis pekerjaan
Pregnancy/home/family needs Dissatisfaction with type of work
Kesehatan Tidak puas terhadap atasan
Poor health/physical disability Dissatisfaction with supervisor
Relokasi ke kota lain Tidak puas terhadap teman kerja
Relocation to another city Dissatisfaction with co-workers
Kesulitan mobilitas Tidak puas dengan lingkungan kerja
Travel difficulties Dissatisfaction with working conditions
Melanjutkan pendidikan Tidak puas dengan benefit dari perusahaan
To attend school Dissatisfaction with benefits
Lainnya (jelaskan dengan rinci)
Other (specify)

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Rencana Setelah Meninggalkan Pekerjaan (Isi dengan singkat)

Plans after Leaving
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BAG. ll SARAN DAN KOMENTAR UNTUK PENGEMBANGAN PERUSAHAAN

PART ll : COMMENTS/SUGGESTIONS FOR IMPROVEMENT
Silahkan mengisi pertanyaan di bawah ini sebagai masukan yang membangun terhadap perusahaan

1. Apa yang anda paling sukai selama bekerja di perusahaan ?

What did you like most about your job?
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2. Apa yang anda paling kurang sukai selama bekerja di perusahaan?
What did you like least about your job?
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3. Bagaimana menurut Anda mengenai gaji,upah dan fasilitas dari perusahaan?

How did you feel about the pay and benefits?
Sangat Baik Baik Cukup Kurang
Excellent Good Fair Poor
Beri nilai untuk penggajian Anda
Rate of pay for your job
Jaminan kesehatan untuk Anda
Medical coverage for self
Jaminan kesehatan untuk tanggungan
Medical coverage for dependents
Asuransi Jiwa
Life insurance
Cuti Sakit
Sick leave

4. Bagaimana pendapat Anda mengenai hal di bawah ini

How did you feel about the following
Tidak Sangat
Sangat Puas Puas Netral
Puas Tidak Puas
Very Slightly Slightly Very
Neutral
Satisfied Satisfied Dissatisfied Dissatisfied
a. Kesempatan dalam menggunakan kemampuan Anda
Opportunity to use your abilities
b. Pengakuan terhadap kinerja Anda
Recognition for the work you did
c. Pelatihan yang Anda dapat
Training you received
d. Metode manajemen dari atasan Anda
Your supervisor’s management methods
e. Kesempatan berdiskusi dengan atasan
The opportunity to talk with your supervisor
f. Informasi mengenai kebijakan, program dan permasalahan
The information you received on policies, programs, projects and problems
g. Informasi yg Anda dapatkan pada struktur department
The information you received on departmental structure
h. Kebijakan dan pelaksanaan Promosi
Promotion policies and practices
i. Kebijakan dan pelaksanaan kedisiplinan mengenai SOP
Discipline policies and practices
j. Sosialisasi tentang kebijakan dan pelaksanaan
Job transfer policies and practices
k. Kebijakan dan pelaksanaan lembur
Overtime policies and practices
l. Kebijakan dan pelaksanaan penilaian performa
Performance review policies and practices
m. Kondisi kerja fisik
Physical working conditions
KOMENTAR
COMMENTS
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5. a) Jika Anda mengambil pekerjaan lain, pekerjaan seperti apa yang ingin Anda lakukan?
a) If you are taking another job, what kind of work will you be doing?
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b) Apa yg membuat tempat kerja anda yg baru lebih menarik dibanding dengan tempat kerja anda saat ini?
b) What has your new place of employment offered you that is more attractive than your present job?
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6. Mungkinkah Universitas telah membuat perbaikan yang mungkin mempengaruhi Anda untuk tetap bekerja?
Could the University have made any improvements that might have influenced you to stay on the job?
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Lainnya (opsional)
Other remarks (optional)
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OPERATION SECTION

PROPOSE LEADER AGREE APPROVED