Issue No.
, Issue date:
Form No.: FORM/ADMIN/09
01 / 18.10.2023
EXIT INTERVIEW FORM
Rev. No., Rev. date:
Page No.: 01 of 02
00 / 00
INFORMATION
Employee name: Employee ID:
Current Position: Department:
Reporting authority Date of
name: resignation:
Initial employment Last date of
date: employment:
Personal email ID: Mobile number:
(optional) (optional)
The objective of this questionnaire is to elicit your honest feedback using which the organization can learn from
its shortcomings. All information provided by you shall be kept confidential and used only for the purpose of
organizational improvement. Consider this feedback as a parting gift to us.
[Link] approximately what point in time did you begin making your decision to resign?
☐ 6 -9 months ago ☐ 3 -5 months ago
☐ 1 -2 months ago ☐ Other, _____________________
[Link] indicate reason(s) below which contributed to your decision to resign your current position?
☐ Salary ☐ Family responsibilities
☐ Job advancement ☐ Dissatisfied
☐ Personal ☐ Benefits
☐ Higher studies ☐ Job eliminated
☐ Relocation ☐ Health retirement
☐ Change in career path ☐ Other, please specify_________________
[Link] there any specific event of issue that prompted your resignation?
☐ Yes ☐ No
[Link] yes, please briefly explain. ___________________________________________________________
_________________________________________________________________________________
[Link] yes, did you discuss this matter with your immediate supervisor / manager?
Issue No., Issue date:
Form No.: FORM/ADMIN/09
01 / 18.10.2023
EXIT INTERVIEW FORM
Rev. No., Rev. date:
Page No.: 02 of 02
00 / 00
☐ Yes ☐ No
_____________________________________________________________________________________
_____________________________________________________________________________________
[Link] you consider returning to work for this company in the future?
_____________________________________________________________________________________
_____________________________________________________________________________________
[Link] did you find most satisfying about your job?
_____________________________________________________________________________________
_____________________________________________________________________________________
[Link] did you find most dissatisfying about your job?
_____________________________________________________________________________________
_____________________________________________________________________________________
[Link] improvements do you think can be made to overall service either internally or externally?
_____________________________________________________________________________________
_____________________________________________________________________________________
10. Check out procedures: I certify that I have returned all ALPHA MD property / asset. Tick in the box,
which is applicable.
☐ Laptop, Mouse, Charger ☐ Books
☐ Keys ☐ Record / Data / Files
☐ Cell phone ☐ Others (Specify)
11. Additional notes on departure: __________________________________________________________
Sign of Employee: Date:
Sign of reporting authority: Date:
Sign of HR / Admin: Date:
Issue No., Issue date:
Form No.: FORM/ADMIN/09
01 / 18.10.2023
EXIT INTERVIEW FORM
Rev. No., Rev. date:
Page No.: 03 of 02
00 / 00
SOP Reference: SOP/ADMIN/06 SOP for recruitment, induction, onboarding and exit of employee
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