EXIT INTERVIEW/INVENTORY
EXIT INTERVIEW/INVENTORY
Program Coordinator
Employee’s Name: _______________________________________________________
Final Date of Employment: ________________ Years with Agency: _______________
_______Resignation was voluntary _________Letter of Resignation Received
_______Termination was involuntary (Record reason in paragraph form, or attach copy of written notification of termination).
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
A. Agency property in possession of employee to be turned over to Supervisor:
Returned/Received by
___Agency Credit Cards and receipts _________________
___Agency Vehicle _________________
___Parking Pass _________________
___Agency Cell Phone and Accessories + charger _________________
___Agency Computer _________________
___Camera _________________
___Memory stick _________________
___Photo ID _________________
___Office Keys _________________
___Petty Cash
___Other:______________________ _________________
B. 1. Has employee completed assigned work?
______Yes ______No ___________________________________
Direct Supervisor Name and Title
___________________________________
Direct Supervisor Signature
2. Office outcome score ________ (attach form)
C. The following items have been discussed:
___ COBRA through Infinisource
___ Life Insurance
___ Long Term Care Insurance
___ Education Assistant Reimbursement
___ Flexible Spending Account
___ 401(k)
___ 401(k) loans
___ Reimbursement Expenses for ________-Check Issue Date: ________________
___ Accrued Leave Days __________ Leave Days taken this month: ______
Leave days to be paid out:__________ (Max payout 10 days)
___ Final Paycheck (Direct Deposit) Check Issue Date: ________________
(Change of Address): _________________________________________
_________________________________________
_________________________________________
D. To be completed by the employee:
_______ I agree with the information listed above.
_______ I do not agree with the information list in the following area(s):
__________________________________________________________________
_______________________________________________________________
____________________________________________ ________________
Employee’s Signature Date
Interview conducted by:
________________________________________________________________________
Name and Title Signature
EXIT INTERVIEW NARRATIVE-EMPLOYEE
Name: _______________________________________
Date: __________________
Length of Service: Dates _____________to _______________ Years ___________
Reason for Leaving: ___________ Voluntary
___________ Involuntary
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
Observations, Experiences, Recommendations:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
EXIT INTERVIEW NARRATIVE-SUPERVISOR
Employee Name: _______________________ Supervisor Name:_________________
What are his/her strengths and deficiencies?
Strengths:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_____________________________________________________________
Deficiencies:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_____________________________________________________________
Would you rehire? ( Yes ( No
Other Comments:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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