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EXIT INTERVIEW FORM

CONFIDENTIAL

SECTION 1: EMPLOYEE INFORMATION

Field Details
Employee Name: [________________________________]
Employee ID: [________________________________]
Job Title/Position: [________________________________]
Department: [________________________________]
Work Location: [________________________________]
Hire Date: [__/__/____]
Last Day Worked: [__/__/____]
Length of Service: [____] years [____] months
Direct Supervisor/Manager: [________________________________]
Interview Conducted By: [________________________________]
Interview Date: [__/__/____]
Interview Method: ☐ In-person ☐ Phone ☐ Video ☐ Written/Survey

SECTION 2: TYPE OF SEPARATION

2.1 Category of Separation:

☐ Voluntary Resignation
☐ Retirement
☐ Involuntary Termination (for cause)
☐ Layoff / Reduction in Force (RIF)
☐ Position Elimination
☐ End of Contract / Temporary Assignment
☐ Mutual Agreement / Separation Agreement
☐ Constructive Discharge (claimed by employee)
☐ Death of Employee
☐ Other: [________________________________]

2.2 Notice Provided:
Notice given by employee: ☐ Yes ☐ No ☐ N/A (involuntary)
Date notice given: [__/__/____]
Amount of notice: [________________________________]
Written resignation received: ☐ Yes ☐ No

2.3 Primary Reason for Leaving (Voluntary Separations):

☐ New job opportunity / career advancement
☐ Higher compensation or better benefits elsewhere
☐ Dissatisfaction with management or leadership
☐ Work-life balance / schedule flexibility
☐ Dissatisfaction with job duties or role
☐ Limited career growth or advancement opportunities
☐ Relocation (personal or family)
☐ Return to school / education
☐ Family or personal reasons
☐ Health or medical reasons
☐ Retirement
☐ Workplace culture or environment
☐ Commute or work location
☐ Better remote/hybrid work arrangement elsewhere
☐ Other: [________________________________]

Elaborate on primary reason:
[________________________________]
[________________________________]
[________________________________]

SECTION 3: JOB SATISFACTION AND ENGAGEMENT

Please rate the following on a scale of 1-5:
(1 = Strongly Disagree, 2 = Disagree, 3 = Neutral, 4 = Agree, 5 = Strongly Agree)

3.1 Job Role and Responsibilities

# Statement Rating (1-5) Comments
1 My job responsibilities were clearly defined. [____] [________________________________]
2 My workload was manageable and reasonable. [____] [________________________________]
3 I had the tools and resources needed to do my job effectively. [____] [________________________________]
4 My skills and abilities were well-utilized in my role. [____] [________________________________]
5 I found my work to be meaningful and engaging. [____] [________________________________]
6 My job description accurately reflected my actual duties. [____] [________________________________]

3.2 Compensation and Benefits

# Statement Rating (1-5) Comments
7 I was fairly compensated for my work. [____] [________________________________]
8 I understood how my pay was determined. [____] [________________________________]
9 The benefits package met my needs. [____] [________________________________]
10 I was satisfied with the PTO/vacation policy. [____] [________________________________]
11 The Company's retirement/401(k) plan was competitive. [____] [________________________________]

3.3 Management and Supervision

# Statement Rating (1-5) Comments
12 My direct supervisor treated me with respect and professionalism. [____] [________________________________]
13 My supervisor provided regular and constructive feedback. [____] [________________________________]
14 My supervisor was accessible and approachable. [____] [________________________________]
15 My supervisor supported my professional development. [____] [________________________________]
16 Expectations were clearly communicated by my supervisor. [____] [________________________________]
17 My supervisor handled conflicts fairly and effectively. [____] [________________________________]
18 I felt comfortable raising concerns with my supervisor. [____] [________________________________]
19 My supervisor recognized and acknowledged good performance. [____] [________________________________]

3.4 Career Development and Growth

# Statement Rating (1-5) Comments
20 I had adequate opportunities for career advancement. [____] [________________________________]
21 I received sufficient training and development opportunities. [____] [________________________________]
22 The Company invested in my professional growth. [____] [________________________________]
23 Internal promotion opportunities were communicated fairly. [____] [________________________________]
24 I had a clear career path within the organization. [____] [________________________________]

3.5 Workplace Culture and Environment

# Statement Rating (1-5) Comments
25 The Company promoted a positive and inclusive work culture. [____] [________________________________]
26 I felt respected and valued as an employee. [____] [________________________________]
27 Communication within the organization was open and transparent. [____] [________________________________]
28 I felt comfortable reporting concerns or problems. [____] [________________________________]
29 The Company's policies were applied consistently and fairly. [____] [________________________________]
30 The physical work environment was safe and comfortable. [____] [________________________________]
31 The Company demonstrated a genuine commitment to diversity, equity, and inclusion. [____] [________________________________]

3.6 Work-Life Balance

# Statement Rating (1-5) Comments
32 The Company supported a healthy work-life balance. [____] [________________________________]
33 I was satisfied with my work schedule and flexibility. [____] [________________________________]
34 Remote/hybrid work arrangements (if applicable) were effective. [____] [________________________________]
35 I did not feel pressured to work unreasonable hours. [____] [________________________________]

3.7 Senior Leadership

# Statement Rating (1-5) Comments
36 I had confidence in senior leadership. [____] [________________________________]
37 Senior leadership communicated a clear vision and direction. [____] [________________________________]
38 Senior leadership was accessible to employees. [____] [________________________________]

SECTION 4: OPEN-ENDED FEEDBACK

4.1 What did you enjoy most about working at [COMPANY NAME]?
[________________________________]
[________________________________]
[________________________________]

4.2 What was the most challenging aspect of your job or the work environment?
[________________________________]
[________________________________]
[________________________________]

4.3 Was there a specific event or experience that prompted your decision to leave?
[________________________________]
[________________________________]
[________________________________]

4.4 What could [COMPANY NAME] have done to retain you?
[________________________________]
[________________________________]
[________________________________]

4.5 What advice would you give to your replacement?
[________________________________]
[________________________________]
[________________________________]

4.6 What improvements would you recommend for the department or the Company as a whole?
[________________________________]
[________________________________]
[________________________________]

4.7 Were there any safety, harassment, discrimination, or ethical concerns that you did not previously report?
☐ No
☐ Yes (please describe): [________________________________]
[________________________________]

4.8 Would you recommend [COMPANY NAME] as a good place to work?
☐ Yes ☐ No ☐ Maybe
Comments: [________________________________]

4.9 Would you consider returning to [COMPANY NAME] in the future?
☐ Yes ☐ No ☐ Maybe
Comments: [________________________________]

SECTION 5: RETURN OF COMPANY PROPERTY

Item Returned? Date Returned Condition Notes
Laptop / Computer ☐ Yes ☐ No ☐ N/A [__/__/____] [________________________________] [________________________________]
Mobile phone ☐ Yes ☐ No ☐ N/A [__/__/____] [________________________________] [________________________________]
Tablet / iPad ☐ Yes ☐ No ☐ N/A [__/__/____] [________________________________] [________________________________]
Security badge / Access card ☐ Yes ☐ No ☐ N/A [__/__/____] [________________________________] [________________________________]
Office/building keys ☐ Yes ☐ No ☐ N/A [__/__/____] [________________________________] [________________________________]
Parking pass ☐ Yes ☐ No ☐ N/A [__/__/____] [________________________________] [________________________________]
Company credit card ☐ Yes ☐ No ☐ N/A [__/__/____] [________________________________] [________________________________]
Company vehicle ☐ Yes ☐ No ☐ N/A [__/__/____] [________________________________] [________________________________]
Uniforms ☐ Yes ☐ No ☐ N/A [__/__/____] [________________________________] [________________________________]
Tools or equipment ☐ Yes ☐ No ☐ N/A [__/__/____] [________________________________] [________________________________]
Documents, files, or records ☐ Yes ☐ No ☐ N/A [__/__/____] [________________________________] [________________________________]
Proprietary or confidential materials ☐ Yes ☐ No ☐ N/A [__/__/____] [________________________________] [________________________________]
Other: [________________] ☐ Yes ☐ No ☐ N/A [__/__/____] [________________________________] [________________________________]
Other: [________________] ☐ Yes ☐ No ☐ N/A [__/__/____] [________________________________] [________________________________]

Outstanding items to be returned by: [__/__/____]
Method of return for outstanding items: ☐ In-person ☐ Shipping (prepaid label provided) ☐ Other: [____]

IT and Access Deprovisioning

Task Completed? Date Completed By
Email access disabled ☐ [__/__/____] [________________________________]
Network/VPN access revoked ☐ [__/__/____] [________________________________]
System login credentials deactivated ☐ [__/__/____] [________________________________]
Cloud storage access revoked ☐ [__/__/____] [________________________________]
Remote access software removed ☐ [__/__/____] [________________________________]
Shared passwords changed/rotated ☐ [__/__/____] [________________________________]
Building/office access deactivated ☐ [__/__/____] [________________________________]
Voicemail forwarded/disabled ☐ [__/__/____] [________________________________]
Out-of-office auto-reply set ☐ [__/__/____] [________________________________]
Personal files removed from Company devices ☐ [__/__/____] [________________________________]

SECTION 6: FINAL PAY AND COMPENSATION

6.1 Final Pay Calculation

Component Amount Notes
Regular wages through last day worked $[________________________________]
Accrued, unused vacation/PTO payout $[________________________________]
Accrued sick leave payout (if applicable) $[________________________________]
Commission payments due $[________________________________]
Bonus payments due $[________________________________]
Expense reimbursements pending $[________________________________]
Deductions (overpayments, advances, etc.) ($[________________________________])
Total Final Pay: $[________________________________]

Method of final pay delivery: ☐ Direct deposit ☐ Check (mailed) ☐ Check (hand-delivered) ☐ Other: [____]

6.2 Forwarding Address for Final Pay and Tax Documents
Street Address: [________________________________]
City, State, ZIP: [________________________________]
Personal Email: [________________________________]
Personal Phone: [________________________________]

SECTION 7: STATE FINAL PAY DEADLINES

State Involuntary Termination Voluntary Resignation Key Statute
California Immediately (same day) 72 hours (or last day if 72+ hours notice given) Cal. Labor Code 201-203
Colorado Immediately Next regular payday Colo. Rev. Stat. 8-4-104
Connecticut Next business day Next regular payday Conn. Gen. Stat. 31-71c
Florida No specific statute (follow FLSA) No specific statute (follow FLSA) N/A
Illinois Next regular payday Next regular payday 820 ILCS 115/5
Massachusetts Day of termination Next regular payday (or Saturday if quit) Mass. Gen. Laws ch. 149 148
Michigan Next regular payday Next regular payday Mich. Comp. Laws 408.475
Montana Immediately (or within 15 days if calculation delay) Next regular payday or 15 days, whichever is earlier Mont. Code Ann. 39-3-205
Nevada Immediately Next regular payday or within 7 days, whichever is earlier Nev. Rev. Stat. 608.020-030
New York Next regular payday Next regular payday N.Y. Labor Law 191
Oregon End of next business day (except by agreement) Next regular payday (with exceptions) Or. Rev. Stat. 652.140
Pennsylvania Next regular payday Next regular payday 43 Pa. Stat. 260.5
Texas Within 6 calendar days Next regular payday Tex. Lab. Code 61.014
Washington End of next regular pay period End of next regular pay period Wash. Rev. Code 49.48.010
[STATE] [________________________________] [________________________________] [________________________________]

Final pay deadline for this employee: [________________________________]
Final pay issued on: [__/__/____]
Compliance confirmed: ☐ Yes ☐ No (explain: [________________________________])

SECTION 8: BENEFITS CONTINUATION (COBRA AND STATE CONTINUATION)

8.1 COBRA Eligibility
Employer has 20+ employees (COBRA applies): ☐ Yes ☐ No
Qualifying event: ☐ Termination ☐ Reduction in hours ☐ Other: [____]
Last day of employer-sponsored coverage: [__/__/____]
COBRA notice mailed/provided: ☐ Yes -- Date: [__/__/____] ☐ Pending
COBRA election deadline (60 days from notice): [__/__/____]
Coverage types available for continuation: ☐ Medical ☐ Dental ☐ Vision ☐ EAP ☐ FSA

8.2 Other Benefits

Benefit Action Required Date / Notes
401(k) / Retirement plan Rollover or distribution options discussed ☐ Yes ☐ N/A
Pension (if applicable) Vesting and distribution information provided ☐ Yes ☐ N/A
Life insurance Portability/conversion options discussed ☐ Yes ☐ N/A
Disability insurance Coverage end date communicated ☐ Yes ☐ N/A
HSA Employee retains ownership; transfer info provided ☐ Yes ☐ N/A
FSA Spending deadline and COBRA option discussed ☐ Yes ☐ N/A
Tuition reimbursement Clawback/repayment obligation reviewed ☐ Yes ☐ N/A
Stock options / equity Vesting schedule and exercise deadlines reviewed ☐ Yes ☐ N/A
Relocation repayment Obligation reviewed ☐ Yes ☐ N/A
Sign-on bonus repayment Obligation reviewed ☐ Yes ☐ N/A
Employee discount programs Access end date communicated ☐ Yes ☐ N/A

8.3 ACA Marketplace Notice

Employee informed of Health Insurance Marketplace options: ☐ Yes ☐ No
Open enrollment period for Marketplace: Typically November 1 - January 15 (or qualifying event = 60-day special enrollment)

SECTION 9: RESTRICTIVE COVENANT AND CONFIDENTIALITY REMINDERS

9.1 Post-Employment Obligations Review

Agreement On File? Reviewed with Employee? Key Terms
Confidentiality / NDA ☐ Yes ☐ No ☐ Yes ☐ No Duration: [____]; Scope: [________________________________]
Non-Compete ☐ Yes ☐ No ☐ Yes ☐ No Duration: [____]; Geographic scope: [________________________________]
Non-Solicitation (clients) ☐ Yes ☐ No ☐ Yes ☐ No Duration: [____]; Scope: [________________________________]
Non-Solicitation (employees) ☐ Yes ☐ No ☐ Yes ☐ No Duration: [____]; Scope: [________________________________]
Invention Assignment / IP ☐ Yes ☐ No ☐ Yes ☐ No Scope: [________________________________]
Arbitration Agreement ☐ Yes ☐ No ☐ Yes ☐ No Survives termination: ☐ Yes ☐ No

9.2 Confidentiality Reminder Statement

I understand that my obligations regarding the protection of [COMPANY NAME]'s confidential information, trade secrets, and proprietary data survive the termination of my employment. I confirm that:

☐ I have returned all Company documents, files, and materials (physical and electronic).
☐ I have not retained copies of any confidential or proprietary information.
☐ I have deleted any Company information from personal devices and accounts.
☐ I understand my continuing obligations under the Defend Trade Secrets Act (18 U.S.C. 1836 et seq.) and applicable state trade secret laws.
☐ I have been provided with copies of all post-employment agreements that remain in effect.

SECTION 10: REFERENCE AND RECOMMENDATION PREFERENCES
May the Company provide a reference for you? ☐ Yes ☐ No
Preferred reference contact at Company: [________________________________]
Authorized to confirm the following:
☐ Dates of employment
☐ Job title and position
☐ Salary or compensation information
☐ Job performance and qualifications
☐ Reason for separation
☐ Eligibility for rehire
Restrictions on references (if any): [________________________________]
Employee eligible for rehire: ☐ Yes ☐ No ☐ Conditional (explain: [____])

SECTION 11: TRANSITION AND KNOWLEDGE TRANSFER

11.1 Knowledge Transfer Checklist

Task Completed? Assigned To Notes
Critical projects and status documented ☐ [________________________________] [________________________________]
Pending deadlines and deliverables identified ☐ [________________________________] [________________________________]
Client/customer handoff plan completed ☐ [________________________________] [________________________________]
Vendor/partner contact information transferred ☐ [________________________________] [________________________________]
Standard operating procedures documented ☐ [________________________________] [________________________________]
Passwords and access credentials transferred ☐ [________________________________] [________________________________]
Ongoing responsibilities reassigned ☐ [________________________________] [________________________________]
Training provided to successor (if applicable) ☐ [________________________________] [________________________________]
Key files and documents organized and accessible ☐ [________________________________] [________________________________]

11.2 Successor Information
Replacement identified: ☐ Yes ☐ No ☐ Position being eliminated
Replacement name (if known): [________________________________]
Interim coverage by: [________________________________]

SECTION 12: UNEMPLOYMENT INSURANCE
Type of separation for UI purposes: ☐ Voluntary quit ☐ Involuntary (not for cause) ☐ Involuntary (for cause) ☐ Layoff/RIF
Will the Company contest a UI claim? ☐ Yes ☐ No ☐ To be determined
Separation documentation on file: ☐ Yes ☐ No

SECTION 13: EMPLOYEE SIGNATURE

I confirm that the exit interview was conducted, and I have been informed of the following:

☐ Final pay timeline and amount
☐ Benefits continuation options (COBRA or state continuation)
☐ Return of Company property requirements
☐ Post-employment confidentiality and restrictive covenant obligations (if applicable)
☐ Reference policy

Participation in this exit interview is voluntary, and my responses will be kept confidential to the extent permitted by law. I understand that my responses will be used to improve the workplace for current and future employees.
Employee Name (Print): [________________________________]
Employee Signature: _______________________________
Date: [__/__/____]

SECTION 14: HR REPRESENTATIVE COMPLETION
HR Representative Name: [________________________________]
HR Representative Signature: _______________________________
Date: [__/__/____]
Checklist Completed:
☐ Exit interview conducted
☐ Final pay processed or scheduled
☐ COBRA notice sent (if applicable)
☐ Company property returned or recovery plan in place
☐ IT access deprovisioned
☐ Post-employment obligations reviewed
☐ Forwarding address on file for W-2 and COBRA
☐ Personnel file updated with separation documentation
☐ Employee removed from active roster and benefit plans
☐ State separation notice filed (if required)
☐ Unemployment insurance documentation prepared

Themes or Trends Noted (HR internal use):
[________________________________]
[________________________________]
[________________________________]

Follow-Up Actions Required:
[________________________________]
[________________________________]
[________________________________]

SOURCES AND REFERENCES

  1. COBRA -- Consolidated Omnibus Budget Reconciliation Act, 29 U.S.C. 1161-1168 (continuation coverage for employers with 20+ employees; employer must notify plan administrator within 30 days of qualifying event; plan administrator must provide election notice within 14 days; 60-day election period for qualified beneficiaries).
  2. California Final Pay -- Cal. Labor Code 201-203 (immediately upon discharge; 72 hours for voluntary quit; waiting time penalties of one day's pay per day late, up to 30 days).
  3. New York Final Pay -- N.Y. Labor Law 191 (next regular payday for all separations).
  4. Texas Final Pay -- Tex. Lab. Code 61.014 (6 calendar days for involuntary; next regular payday for voluntary quit).
  5. Colorado Final Pay -- Colo. Rev. Stat. 8-4-104 (immediately upon discharge; next regular payday for voluntary quit).
  6. Illinois Final Pay -- 820 ILCS 115/5 (next regular payday for all separations).
  7. Defend Trade Secrets Act -- 18 U.S.C. 1836 et seq. (federal trade secret protection; 18 U.S.C. 1833(b) provides whistleblower immunity).
  8. ERISA -- Employee Retirement Income Security Act, 29 U.S.C. 1001 et seq. (governs retirement plan distributions and rollovers upon separation).
  9. ACA Marketplace -- Affordable Care Act special enrollment period: 60 days from loss of employer-sponsored coverage; https://www.healthcare.gov.
  10. State Unemployment Insurance -- State-specific eligibility rules; generally, voluntary quits without good cause and terminations for misconduct are disqualifying.

This template is provided by ezel.ai for informational purposes only and does not constitute legal advice. Exit interview and separation procedures must comply with applicable federal, state, and local employment laws. This document must be reviewed and customized by a qualified attorney before use. No attorney-client relationship is created by use of this template.

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EXIT INTERVIEW FORM

GENERAL TEMPLATE

Effective Date: [DATE]
Party A: [PARTY A NAME]
Address: [PARTY A ADDRESS]
Party B: [PARTY B NAME]
Address: [PARTY B ADDRESS]
Governing Law: [GOVERNING STATE]
This document is entered into by and between [PARTY A NAME] and [PARTY B NAME], effective as of the date set forth above, subject to the terms and conditions outlined herein and the laws of [GOVERNING STATE].
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