EXIT INTERVIEW FORM

In order to maintain a positive working environment at Goswami Hospital, we request your cooperation in
providing suggestions and comments to assist us in accomplishing this goal. You are a valuable source of
information regarding working conditions. Please be candid with your answers so we may gain from your
experience here at GH. All information will remain confidential.

Name:

Position:

Supervisor:

Joining Date: Relieving Date:

A. Reason for leaving. Please tick all that is applicable

Personal Quantity of work
Family Circumstances Working conditions
Health Reasons Problems with work schedule
Relocation Not satisfied with salary
For Higher Studies Benefits
Accepted another job Relationship with supervisor
Retirement Lack of training
Lack of promotional opportunity
Other
B. How would you rate your supervisor on the following elements?

Excellent Good Fair Poor

1. Demonstrates fair and equal treatment

2. Facilitates cooperation and teamwork

3. Provides recognition on the job
4. Encourages feedback/listens to suggestions.
5. Effectively resolves complaints and grievances
6. Demonstrates ownership for the team
 C. How would you rate the following in relation to your job?

Excellent Good Fair Poor

Communications between you and your
1.
manager
2. Morale in your department
3. Job satisfaction
4. Training you received
5. Growth potential

D. Job Feedback

11. To what extent did you have the opportunity to use your abilities while working here?

12. Was the job you performed the one you applied for? Yes No

13. Do you feel you were delegated the appropriate responsibility? Yes No

14. What were some of the frustrations you experienced in the performance and execution of your job
responsibilities?

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15. Did you receive on the job training to help you improve your work? Yes No

17. Would you recommend

Goswami Hospital as a place to work? Yes, without reservation Yes, with reservations
Your Department as a place to work? Yes, without reservation Yes, with reservations

18. What constructive comments would you have for management in regard to making GH or your
department a better place?

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Are there any comments you would like to make (including comments on this survey)?
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