HR Exit Survey

HR EXIT SURVEY

Personal Information

Employee Name:

Position Information

Hire Date:     Last Day of Work:

Employment History (Most Recent Employers)

Employer 1

Start Date:     End Date:

Employer 2

Start Date:     End Date:

Education

Graduation Date:

References

Reference 1

Reference 2

Reference 3

Exit Survey Questions

Personal reasons / family
Career advancement / new opportunity
Compensation / benefits
Management / supervision concerns
Work environment / culture
Relocation
Other

Compensation:   Benefits:   Workload:   Management:

Yes    No

Yes    No    Maybe, under conditions

Voluntary    Involuntary / Terminated

Return of Company Property & Final Pay

Please indicate items to be returned (computer, keys, ID badge, company phone, other):

Yes    No — outstanding items:

Legal Disclosures & Acknowledgments

At-Will Employment: I acknowledge that my employment with the organization was at-will unless modified in a signed written agreement. I understand that either I or the organization may terminate employment at any time, with or without cause or prior notice, except where prohibited by law.

Equal Opportunity: The organization provides equal employment opportunity to all employees and applicants without regard to protected characteristics. Any claim of discrimination or harassment reported in this form will be handled in accordance with company policy and applicable law.

Confidentiality and Return of Records: I acknowledge my continuing obligations, if any, under confidentiality, nondisclosure, trade secret, or similar post-employment provisions contained in my employment agreement or company policy. I confirm I will not retain or disclose proprietary or confidential company information.

I authorize the organization to contact prior employers and professional references listed on this form for the purpose of evaluating employment history or verifying information. I consent to release of information necessary for employment-related verifications and to background or records checks consistent with applicable law.

I certify that all information provided on this exit survey is true and complete to the best of my knowledge and that I understand any false statements or omissions may subject me to post-employment action where permitted by law.

By signing below I certify that the statements in this exit survey are accurate and that I provide the authorizations contained herein voluntarily.

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