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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