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:


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: