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1. Name: *



2. Department: *



3. Job Title:



4. Major job responsibilities:



5. Date of Hire:

Select a date from the calendar.

6. Last day of employment:

Select a date from the calendar.

7. Reason for leaving your County position: *



8. If leaving for another position, what organization will you be working for?



9. Are you leaving for more pay? *


If yes, new salary:



10. Are you leaving for better benefits? *


If yes, which benefits:



11. Please rate your satisfaction of your county position and what you liked and disliked about working here. (Please select one response for each item).
Job Training:



Relationship with co-workers:


Work site:


Working conditions:


Compensation:


Employee Benefits:


Opportunity for advancement:


Flexible work schedule:


Job security:


Supervisor's style:


Organization's philosophy:


Communication with supervisor:


Importance of work to organization:


Good use of abilities:


12. Do you have any suggestions for improving work procedures and/or environment:



13. Please add any other comments you believe will help us improve employee satisfaction: