Name of the Employee *

Date *

1. What are your reasons for leaving this company? *

2. How effectively were your skills put to use at this company? *

3. How easy was it to get the resources you needed to do your job well at this company? *

4. How much room for professional growth did you have at this company? *

5. How well were you paid for the work you did at this company? *

6. How fairly were you treated by your supervisor at this company? *

7. How consistently did your supervisor reward you for good work? *

8. How realistic were the expectations of your supervisor? *

9. How reasonable were the decisions made by your supervisor? *

10. How often did your supervisor listen to employees' opinions when making decisions? *

11. How easy was it for employees to disagree with the decisions made by your supervisor? *

12. How well did your supervisor handle employee problems? *

13. How well did the members of your team work together to reach a common goal? *

14. In a typical week, how often did you feel stressed at work? *

15. How easy was it to balance your work life and personal life while working at this company? *

16. How safe did you feel at your employer's workplace? *

17. How comfortable was your employer's work environment? *

18. Was your employer's work environment positive, neither positive nor negative, or negative? *

19. Was your employer's health insurance plan better, worse, or about the same as those of other employers? *

20. What actions can your employer take to build a better workplace? *

21. Overall, did you like working with your employer, neither like nor dislike it, or dislike it? *

22. Additional Comment (Optional)