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Fields
Name
*
First Name
*
Middle Name (optional)
Last Name
*
Date of Hire
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Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Title
Supervisor
Department you worked in:
*
Development
Marketing
Sales
Search Marketing
Software Design
Support
Web Design
What Prompted you to seek alternative employment? (Check all that apply)
*
Type of Work
Compensation
Lack of Recognition
Company Culture
Business/Product Direction
Quality of Supervision
Work Conditions
Family Circumstances
Career Advancement Opportunity
Other:
Other Value
Before making your decision to leave, did you investigate other options that would enable you to stay?
Yes
No
Please describe your investigation of other options where you would have stayed:
What did you think of your supervision in regards to the following?
What did you think of your supervision in regards to the following?
Almost Always
Sometimes
Never
Demonstrated fair and equal treatment
What did you think of your supervision in regards to the following?: Demonstrated fair and equal treatment (Almost Always)
Demonstrated fair and equal treatment (Sometimes)
Demonstrated fair and equal treatment (Never)
Provided recognition on the job
Provided recognition on the job (Almost Always)
Provided recognition on the job (Sometimes)
Provided recognition on the job (Never)
Developed cooperation and teamwork
Developed cooperation and teamwork (Almost Always)
Developed cooperation and teamwork (Sometimes)
Developed cooperation and teamwork (Never)
Encouraged/listened to suggestions
Encouraged/listened to suggestions (Almost Always)
Encouraged/listened to suggestions (Sometimes)
Encouraged/listened to suggestions (Never)
Resolved complaints and problems
Resolved complaints and problems (Almost Always)
Resolved complaints and problems (Sometimes)
Resolved complaints and problems (Never)
Followed policies and practices
Followed policies and practices (Almost Always)
Followed policies and practices (Sometimes)
Followed policies and practices (Never)
How would you rate the following in relation to your job?
How would you rate the following in relation to your job?
Excellent
Good
Fair
Poor
Cooperation within your department
How would you rate the following in relation to your job?: Cooperation within your department (Excellent)
Cooperation within your department (Good)
Cooperation within your department (Fair)
Cooperation within your department (Poor)
Cooperation with other departments
Cooperation with other departments (Excellent)
Cooperation with other departments (Good)
Cooperation with other departments (Fair)
Cooperation with other departments (Poor)
Communications in your department
Communications in your department (Excellent)
Communications in your department (Good)
Communications in your department (Fair)
Communications in your department (Poor)
Communications within the company as a whole
Communications within the company as a whole (Excellent)
Communications within the company as a whole (Good)
Communications within the company as a whole (Fair)
Communications within the company as a whole (Poor)
Communications between you and your manager
Communications between you and your manager (Excellent)
Communications between you and your manager (Good)
Communications between you and your manager (Fair)
Communications between you and your manager (Poor)
Morale in your department
Morale in your department (Excellent)
Morale in your department (Good)
Morale in your department (Fair)
Morale in your department (Poor)
Job Satisfaction
Job Satisfaction (Excellent)
Job Satisfaction (Good)
Job Satisfaction (Fair)
Job Satisfaction (Poor)
Training you received
Training you received (Excellent)
Training you received (Good)
Training you received (Fair)
Training you received (Poor)
Growth Potential
Growth Potential (Excellent)
Growth Potential (Good)
Growth Potential (Fair)
Growth Potential (Poor)
Any Additional Comments Regarding Your Supervision or Job?
Are you leaving on good terms?
Yes
No
Was your workload usually:
Too great
Varied, but all right
About right
Too light
How did you feel about your salary and the employee benefits offered?
How did you feel about your salary and the employee benefits offered?
Excellent
Good
Fair
Poor
Base Salary
How did you feel about your salary and the employee benefits offered?: Base Salary (Excellent)
Base Salary (Good)
Base Salary (Fair)
Base Salary (Poor)
Medical Plan
Medical Plan (Excellent)
Medical Plan (Good)
Medical Plan (Fair)
Medical Plan (Poor)
Dental Plan
Dental Plan (Excellent)
Dental Plan (Good)
Dental Plan (Fair)
Dental Plan (Poor)
Vision Plan
Vision Plan (Excellent)
Vision Plan (Good)
Vision Plan (Fair)
Vision Plan (Poor)
401K Plan
401K Plan (Excellent)
401K Plan (Good)
401K Plan (Fair)
401K Plan (Poor)
Life Insurance
Life Insurance (Excellent)
Life Insurance (Good)
Life Insurance (Fair)
Life Insurance (Poor)
Paid-Time-Off
Paid-Time-Off (Excellent)
Paid-Time-Off (Good)
Paid-Time-Off (Fair)
Paid-Time-Off (Poor)
Short Term Disability/Long Term Disability
Short Term Disability/Long Term Disability (Excellent)
Short Term Disability/Long Term Disability (Good)
Short Term Disability/Long Term Disability (Fair)
Short Term Disability/Long Term Disability (Poor)
Stock Options
Stock Options (Excellent)
Stock Options (Good)
Stock Options (Fair)
Stock Options (Poor)
Are there any other benefits you feel should have been offered?
Yes
No
What other benefits do you feel should have been offered?
Any other comments on employee benefits or salary?
How often did you...
How often did you...
Regularly
Sometimes
Never
receive feedback from your manager on your performance?
How often did you...: receive feedback from your manager on your performance? (Regularly)
receive feedback from your manager on your performance? (Sometimes)
receive feedback from your manager on your performance? (Never)
have discussions with your manager about career goals?
have discussions with your manager about career goals? (Regularly)
have discussions with your manager about career goals? (Sometimes)
have discussions with your manager about career goals? (Never)
How did you feel about your manager providing performance feedback?
How did you feel about your discussions with your manager about your career goals?
What did you like most about your job and/or this company?
What did you like least about your job and/or this company?
What does your new job offer that your job with this company does not?
Why is the new job/company better?
Do you have any suggestions for improvement? Have you raised them in the past?
Would you recommend this company to a friend as a place to work?
Yes, without reservations
Yes, but with reservations
No
Additional comments about your job or this company:
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