Description
Your honest and open responses are important to us. Once completed, the information from the questionnaire will be confidentially reviewed in Human Resources and will not be entered into your personnel file.
Last revised 08/2014 Page 1 of 5 Form HR-ER03
EXIT INTERVIEW QUESTIONNAIRE
Labor and Employee Relations
A Commonwealth University
Introduction
Please help us make Temple University a better place to work by completing the following questionnaire. Your
honest and open responses are important to us. Once completed, the information from the questionnaire will be
confidentially reviewed in Human Resources and will not be entered into your personnel file. The data obtained will
be used to identify trends, recognize areas exceeding expectations and provide feedback to improve the work
culture. It will serve to enable us in developing policies and practices that reflect the needs of our employees. Your
signature on the form is optional. Your responses will not affect future references or prospects for reemployment.
Please contact Labor/Employee Relations at (215) 926-2298 if you would like to schedule an optional personal exit
interview.
Completing This Form (for employee only)
Please complete this form by printing using blue or black ink. For each section, please check the box that most
clearly represents your position. Once completed, please return form directly to Human Resources. You can send
or fax this questionnaire to Employee Relations at TASB (083-39), 1852 North 10
th
Street, Philadelphia, PA 19122.
Fax: (215) 926 – 2299.
Name: _______________________________________ Date of Birth: ___/___/___ (Month, Day, Year)
Telephone: ( ) _____________ - _________________ Gender: ? Male ? Female
Race: Check one): ? African American ? Asian ? Caucasian ? Hispanic ? Other
D
epartment: _____________________________________ Position /Title: __________________________
J
ob Level: _______ Name of Manager/Supervisor: _______________________________________
Full Time: ? Part Time ?
Today’s Date: ___/___/___ Last Date of Employment: ___/___/___
Date of Hire: ___/___/___ Total Length of Service: _________
I. REASON FOR LEAVING TEMPLE (Please check all that apply)
? Career Development ? Military Service ? Marriage, divorce, death in family
? Working conditions ? Location (traveling distance) ? Return to school
? Difficult co-workers ? Compensation ? Retirement
? Personal Health ? Supervision ? Job Security
? Relocation ? Maternity ? Job eliminated
? Other (please explain below)
Please explain:_________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
II. WORK AND WORK ENVIRONMENT (Please rate the following factors.)
Strongly Disagree Disagree Neutral Agree Strongly Agree
In my current work environment:
I found my work challenging ? ? ? ? ?
I made a difference ? ? ? ? ?
I had a fair workload ? ? ? ? ?
I had the tools needed to do good work ? ? ? ? ?
Different opinions were valued ? ? ? ? ?
My work group worked as a team ? ? ? ? ?
My department worked as a team ? ? ? ? ?
Comments:
III. LEARNING AND DEVELOPMENT (Please rate the following factors.)
Opportunities for learning and
development:
Were adequate within my department
Provided me with the potential for
career growth
Last revised 08/2014 Page 2 of 5 Form HR-ER03
Contributed to opportunities for
advancement
Strongly Disagree
?
?
?
Disagree
?
?
?
Neutral
?
?
?
Agree
?
?
?
Strongly Agree
?
?
?
Comments:
IV. SUPERVISION (How would you rate your supervisor on the following?)
My supervisor consistently:
Followed policies and procedures
Treated me fairly and consistently
Provided me with recognition and praise
Developed cooperation among staff
Facilitated my career and development
Encouraged my suggestions
Resolved my complaints and issues
Listened to my ideas
Recognized my contributions
I witnessed or saw evidence of non-compliance
to rules, regulations, laws policies and
procedures in the workplace
I was provided with adequate compliance
guidance to properly do my job in regard to
following rules, regulations, laws, policies, and
procedures, etc? (i.e. training, orientation, in-
service, etc.)
Strongly Disagree
?
?
?
?
?
?
?
?
?
?
?
(Please explain
below)
Disagree
?
?
?
?
?
?
?
?
?
?
?
(Please
explain below)
Neutral
?
?
?
?
?
?
?
?
?
?
?
Agree
?
?
?
?
?
?
?
?
?
?
(Please explain
below)
?
Strongly Agree
?
?
?
?
?
?
?
?
?
?
(Please explain
below)
?
Explanation:
Explanation:
Last revised 08/2014 Page 3 of 5 Form HR-ER03
V. REWARDS (Please rate the following components of your compensation.)
My base salary was adequate
My annual increases were sufficient
The benefits package met my needs
(medical, dental, retirement, education, and
vacation/PTO)
Premium pay is adequate
(shift, weekend option, call back, stand by)
My contributions were rewarded fairly
within the confines of the University’s
parameters.
The reward system met my needs
(pay, recognition, promotions)
Strongly Disagree
?
?
?
?
?
?
Disagree
?
?
?
?
?
?
Neutral
?
?
?
?
?
?
Agree
?
?
?
?
?
?
Strongly Agree
?
?
?
?
?
?
Comments:
VI. SUMMARY (Please complete the following)
What did you like most about working at Temple?
What work related issues, areas, policies or benefits would you like to see improved?
Last revised 08/2014 Page 4 of 5 Form HR-ER03
Would you consider re-employment at Temple? Why or why not?
Would you recommend Temple employment to others?
What changes would be required to attract you back to Temple?
Would you like a follow-up call? ? Yes ? No
Employee Signature: __________________________________________________________
Exit Interviewer Signature: ______________________________________________________
(Department of Human Resources Representative Only)
Exit Interviewer Name (Print): ___________________________________________________
Last revised 08/2014 Page 5 of 5 Form HR-ER03
doc_472860509.pdf
Your honest and open responses are important to us. Once completed, the information from the questionnaire will be confidentially reviewed in Human Resources and will not be entered into your personnel file.
Last revised 08/2014 Page 1 of 5 Form HR-ER03
EXIT INTERVIEW QUESTIONNAIRE
Labor and Employee Relations
A Commonwealth University
Introduction
Please help us make Temple University a better place to work by completing the following questionnaire. Your
honest and open responses are important to us. Once completed, the information from the questionnaire will be
confidentially reviewed in Human Resources and will not be entered into your personnel file. The data obtained will
be used to identify trends, recognize areas exceeding expectations and provide feedback to improve the work
culture. It will serve to enable us in developing policies and practices that reflect the needs of our employees. Your
signature on the form is optional. Your responses will not affect future references or prospects for reemployment.
Please contact Labor/Employee Relations at (215) 926-2298 if you would like to schedule an optional personal exit
interview.
Completing This Form (for employee only)
Please complete this form by printing using blue or black ink. For each section, please check the box that most
clearly represents your position. Once completed, please return form directly to Human Resources. You can send
or fax this questionnaire to Employee Relations at TASB (083-39), 1852 North 10
th
Street, Philadelphia, PA 19122.
Fax: (215) 926 – 2299.
Name: _______________________________________ Date of Birth: ___/___/___ (Month, Day, Year)
Telephone: ( ) _____________ - _________________ Gender: ? Male ? Female
Race: Check one): ? African American ? Asian ? Caucasian ? Hispanic ? Other
D
epartment: _____________________________________ Position /Title: __________________________
J
ob Level: _______ Name of Manager/Supervisor: _______________________________________
Full Time: ? Part Time ?
Today’s Date: ___/___/___ Last Date of Employment: ___/___/___
Date of Hire: ___/___/___ Total Length of Service: _________
I. REASON FOR LEAVING TEMPLE (Please check all that apply)
? Career Development ? Military Service ? Marriage, divorce, death in family
? Working conditions ? Location (traveling distance) ? Return to school
? Difficult co-workers ? Compensation ? Retirement
? Personal Health ? Supervision ? Job Security
? Relocation ? Maternity ? Job eliminated
? Other (please explain below)
Please explain:_________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
II. WORK AND WORK ENVIRONMENT (Please rate the following factors.)
Strongly Disagree Disagree Neutral Agree Strongly Agree
In my current work environment:
I found my work challenging ? ? ? ? ?
I made a difference ? ? ? ? ?
I had a fair workload ? ? ? ? ?
I had the tools needed to do good work ? ? ? ? ?
Different opinions were valued ? ? ? ? ?
My work group worked as a team ? ? ? ? ?
My department worked as a team ? ? ? ? ?
Comments:
III. LEARNING AND DEVELOPMENT (Please rate the following factors.)
Opportunities for learning and
development:
Were adequate within my department
Provided me with the potential for
career growth
Last revised 08/2014 Page 2 of 5 Form HR-ER03
Contributed to opportunities for
advancement
Strongly Disagree
?
?
?
Disagree
?
?
?
Neutral
?
?
?
Agree
?
?
?
Strongly Agree
?
?
?
Comments:
IV. SUPERVISION (How would you rate your supervisor on the following?)
My supervisor consistently:
Followed policies and procedures
Treated me fairly and consistently
Provided me with recognition and praise
Developed cooperation among staff
Facilitated my career and development
Encouraged my suggestions
Resolved my complaints and issues
Listened to my ideas
Recognized my contributions
I witnessed or saw evidence of non-compliance
to rules, regulations, laws policies and
procedures in the workplace
I was provided with adequate compliance
guidance to properly do my job in regard to
following rules, regulations, laws, policies, and
procedures, etc? (i.e. training, orientation, in-
service, etc.)
Strongly Disagree
?
?
?
?
?
?
?
?
?
?
?
(Please explain
below)
Disagree
?
?
?
?
?
?
?
?
?
?
?
(Please
explain below)
Neutral
?
?
?
?
?
?
?
?
?
?
?
Agree
?
?
?
?
?
?
?
?
?
?
(Please explain
below)
?
Strongly Agree
?
?
?
?
?
?
?
?
?
?
(Please explain
below)
?
Explanation:
Explanation:
Last revised 08/2014 Page 3 of 5 Form HR-ER03
V. REWARDS (Please rate the following components of your compensation.)
My base salary was adequate
My annual increases were sufficient
The benefits package met my needs
(medical, dental, retirement, education, and
vacation/PTO)
Premium pay is adequate
(shift, weekend option, call back, stand by)
My contributions were rewarded fairly
within the confines of the University’s
parameters.
The reward system met my needs
(pay, recognition, promotions)
Strongly Disagree
?
?
?
?
?
?
Disagree
?
?
?
?
?
?
Neutral
?
?
?
?
?
?
Agree
?
?
?
?
?
?
Strongly Agree
?
?
?
?
?
?
Comments:
VI. SUMMARY (Please complete the following)
What did you like most about working at Temple?
What work related issues, areas, policies or benefits would you like to see improved?
Last revised 08/2014 Page 4 of 5 Form HR-ER03
Would you consider re-employment at Temple? Why or why not?
Would you recommend Temple employment to others?
What changes would be required to attract you back to Temple?
Would you like a follow-up call? ? Yes ? No
Employee Signature: __________________________________________________________
Exit Interviewer Signature: ______________________________________________________
(Department of Human Resources Representative Only)
Exit Interviewer Name (Print): ___________________________________________________
Last revised 08/2014 Page 5 of 5 Form HR-ER03
doc_472860509.pdf