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Check which best describes your feeling about the following aspects of your employment. This information will be kept confidential in that you are not required to put your name on the form.
Very Satisfied Satisfied Dissatisfied
Duties of the job
Training & development programs
Opportunities for advancement
Salary treatment
Benefit programs
Working conditions
Working hours
Co-workers
Supervision
Overall, as a place to work
 
 
 
Gender:
 
Female
 
Male
 
 
 
Department:
   
 
 
 
Reason for Leaving: (Check all that apply)
 
Benefits
 
Better job opportunity
 
Commute
 
Family reasons
 
Not challenged
 
Pay
 
Personal reasons
 
Relocation/move
 
Return to school
 
Supervision
 
Work relationships
 
Health

 
 
 
Additional comments
   
 
 
 
How long have you worked for (Company)?
 
Less than 1 months
 
3 months - 1 year
 
1 - 3+ years
 
4 - 6+ years
 
7 - 10+ years
 
10+ years
 
 
 
Please indicate your level of agreement with each of the following statements
 
 
Very   
satisfied   
Somewhat   
satisfied   
Neutral     Somewhat  
dissatisfied    
Very    
dissatisfied    
N/A
Salary
Benefits
Frequency and amount of bonuses
Connection between pay and performance
Security and administration of your 401(k)/stock options/pension plans
Workload
Flexibility of work hours
Physical working environment
Opportunity for advancement
Job security
Very   
satisfied   
Somewhat   
satisfied   
Neutral     Somewhat  
dissatisfied    
Very    
dissatisfied    
N/A
Ability to influence decisions that affect you
Ability to influence day-to-day company success
Opportunity to use new technologies
Opportunity to work on interesting projects
Access to company-sponsored training and seminars
Communication with your supervisor
Recognition received from your supervisor
Your supervisor's management capabilities
Your supervisor's active involvement in your career development
Your overall relationship with your supervisor
Your relationship with your peers
Your relationship with customers/clients/end users
Your understanding of the business mission
Your overall satisfaction with your company
Overall satisfaction with your job
 
 

Your Manager:
Strongly   
agree   
Agree    Neutral    Disagree    Strongly   
disagree   
N/A
Effectively leads the department
Communicates well with subordinates
Recognizes good work
Has good leadership qualities
 
 
 
How long have you worked for (Company)?
 
Less than 3 months
 
3 months - 1 year
 
1 - 3+ years
 
4 - 6+ years
 
7 - 10+ years
 
10+ years
 
 
 
Please indicate your level of agreement with each of the following statements
 
 
Very   
satisfied   
Somewhat   
satisfied   
Neutral     Somewhat  
dissatisfied    
Very    
dissatisfied    
N/A
Salary
Benefits
Frequency and amount of bonuses
Connection between pay and performance
Security and administration of your 401(k)/stock options/pension plans
Workload
Flexibility of work hours
Physical working environment
Opportunity for advancement
Job security
Very   
satisfied   
Somewhat   
satisfied   
Neutral     Somewhat  
dissatisfied    
Very    
dissatisfied    
N/A
Ability to influence decisions that affect you
Ability to influence day-to-day company success
Opportunity to use new technologies
Opportunity to work on interesting projects
Access to company-sponsored training and seminars
Communication with your supervisor
Recognition received from your supervisor
Your supervisor's management capabilities
Your supervisor's active involvement in your career development
Your overall relationship with your supervisor
Your relationship with your peers
Your relationship with customers/clients/end users
Your understanding of the business mission
Your overall satisfaction with your company
Overall satisfaction with your job
 
 

Your Manager:
Strongly   
agree   
Agree    Neutral    Disagree    Strongly   
disagree   
N/A
Effectively leads the department
Communicates well with subordinates
Recognizes good work
Has good leadership qualities
 
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