Doc. Id. No.

HR-4322-19
EMPLOYEE EXIT INTERVIEW Revision No. 1
FORM Effective Date: 16/06/2015
Doc. Ctrl. No.

CONFIDENTIAL
Name of Employee : ______________________________________________________________
Departement : _______________________ Supervisor :
________________
Date Hired : _______________________ Date Quit :
________________
Starting Position : _______________________ Ending Position :
________________
Starting Salary : _______________________ Ending Salary :
________________

PART I : REASONS FOR LEAVING

More than one reason may be given if appropriate; if so, circle primary reason.

 RESIGNATION
1.
2. Take another position 9. Dissatisfcation with type of work
3. Pregnancy/home/family needs 10. Dissatisfaction with supervisor
4. Poor health/physical disability 11. Dissatisfaction with co-workers
5. Relocation to another city 12. Dissatisfaction with working
6. Travel difficulties conditions
7. To attend school 13. Dissatifcation with benefits
8. Dissatisfaction with salary
Others (please specify) :
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____________________________
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 TERMINATION
1. On his/her resignation from the services of the company;
2. On being removed from the services or on being dismissed by the company;
3. On the expiry of any fixed contract period;
4. On being found medically unfit to continue working in his/her present responsibility;
Others (please specify) :
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______________________________________________________________________
____________________________
______________________________________________________________________
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 RETIREMENT
1. Voluntary retirement
2. Disability retirement
3. Regular retirement
Others (please specify):
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______________________________________________________________________
____________________________
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______________

PLANS AFTER LEAVING:

______________________________________________________________________
______________________________________________________________________
____________________________
______________________________________________________________________
______________________________________________________________________
____________________________
______________________________________________________________________
______________PART II: COMMENTS/ SUGGESTIONS FOR IMPROVEMENT
Please complete this form.

1. What did you like most about your job?

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____________________________
______________________________________________________________________
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______________________________________________________________________
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2. What did you like least about your job?
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____________________________
______________________________________________________________________
______________
______________________________________________________________________
______________

3. How did you feel about the pay and benefits?

Excellent Good Fair

Poor
 Rate of pay for your job  BPJS Kesehatan
 Paid leave  Life Insurance
 BPJS Ketenagakerjaan  Sick Leave
4. How did you feel about the following:

Very Slightly Neutral Slightly Very

Satisfied Satisfied Dissatisfied Dissatisfied
Opportunity to use your
abilities
Recognition for the work
you did
Training your received
Your supervisor’s
management methods
The opportunity to talk
with your supervisor
The information you
received on policies,
programs, projects and
problems
The information you
received on departmental
structures
Promotion policies and
practices
Discipline policies and
practices
Job transfer policies and
practices
Overtime policies and
practices
Performance review
policies and practices
Physical working
conditions

COMMENTS :
______________________________________________________________________
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5. If you are taking another job, what kind of work will you be doing?
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6. What has your new place of employment offered you that is more attractive than your
present job?
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7. Could the company have made any improvements that might have influenced you to
stay on the job?
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Other remarks (optional):

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Employee signature:

_________________________
Date:

Prepared by:

__________________________
Hiring and Recruitment Officer