Separation / Exit

Exit Interview & Separation Documentation

Use this form when an employee or independent contractor resigns or is terminated. The purpose is to document the reason for separation and capture feedback that can be used for quality improvement and HR review.

One Exit Interview per separation. File together with the termination notice, final evaluation, and any related correspondence in the personnel record.

Separation Summary

Reason for leaving • Feedback • Property returned

Exit Interview

Complete this form at or near the time of separation. If the employee is unavailable or declines, document the reason in the section provided.

Employee / Contractor Name

Title / Position

Status

Department / Service Line

Date of Hire

Last Day Worked

Date of Resignation / Termination

Type of Separation

1. Most important reason for leaving

2. Was the information given to you about your job (hours, salary, job duties) an accurate reflection of what you found on the job?

3. Were you adequately prepared to perform your job? If not, what could have been done to help you perform more effectively?

4. What did you like best about working for the agency?

5. What did you like the least about working for the agency?

6. Did you receive sufficient information about your performance?

7. Suggestions to improve Saintly Home Health as an employer

Agency property / access returned or removed

Eligible for rehire?

Rehire notes / conditions (if applicable)

Exit interview completed by

Interviewer Role / Title

Date exit interview completed

Employee acknowledgment (type full name, if interviewed)

Reason(s) why the exit interview was not completed (if applicable)

This exit interview will be emailed to the HR inbox and should be printed or saved to the employee’s personnel record along with all separation documents.