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1/5

Employee Retention Questionnaire

SECTION 1

Professional Background Information1. How long ago did you leave your prior company?

(yy/mm)

2. How long were you employed by your prior company?(yy/mm)

3. How long were you in your final position?

(yy/mm)

4. What was your final job title?

5. What is your Occupation?

6. What is your Industry?

7. What is your highest level of formal education?

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SECTION 2

Factors Influencing Decision to Leave

Please circle the response which best corresponds to the degree to which

each of the following factor influenced or was the reason for your decision

to leave

1 = None, 2 = Weak, 3 = Moderate, 4 = Moderate/Strong, 5 = Strong

Influence, n/a = Non ApplicableFactors Influencing Decision to Leave

Another position / career opportunity 1 2 3 4 5 n/a

Dissatisfaction with pay 1 2 3 4 5 n/a

Lack of recognition 1 2 3 4 5 n/a

Dissatisfaction with benefits 1 2 3 4 5 n/a

Working conditions 1 2 3 4 5 n/a

Quality of supervision 1 2 3 4 5 n/a

Type of work 1 2 3 4 5 n/a

Conflict(s) with co-worker(s) 1 2 3 4 5 n/a

No advancement opportunities 1 2 3 4 5 n/a

Health problems 1 2 3 4 5 n/a

Care for family member 1 2 3 4 5 n/a

Transportation problems 1 2 3 4 5 n/a

Vacations/time off 1 2 3 4 5 n/a

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Company culture 1 2 3 4 5 n/a

Business/product direction 1 2 3 4 5 n/a

SECTION 3

Job and Company Environment Activities and

Characteristics

Please rate your position with your former employer on thefollowing activities and characteristics

1 =Poor, 2 = Below Average, 3 = Average, 4 = AboveAverage, 5 = Excellent, n/a = Non ApplicableCompany Factors

Orientation and Initial Training 1 2 3 4 5 n/a

Ongoing Training 1 2 3 4 5 n/a

Opportunities for Growth 1 2 3 4 5 n/a

and Advancement

Appreciation/Recognition 1 2 3 4 5 n/a

Performance Feedback 1 2 3 4 5 n/a

Quality of Supervision 1 2 3 4 5 n/aJob Expectations vs Reality 1 2 3 4 5 n/a

Working Environment 1 2 3 4 5 n/a

Cooperation 1 2 3 4 5 n/a

Communications 1 2 3 4 5 n/a

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Job Satisfaction 1 2 3 4 5 n/a

Salary and Benefits 1 2 3 4 5 n/a

SECTION 4

Individual Performance and QualificationsRelated Activities and Characteristics

Please rate yourself compared to others in your formercompany on the following activities and characteristics1 =below 50%, 2 = top 50 to 75%, 3 = top 25 to 10%, 4 =top 5 to 10% , 5 = top 5% , n/a = Non ApplicableIndividual Factors

Overall Performance 1 2 3 4 5 n/a

Quality of Work 1 2 3 4 5 n/a

Quantity of Work 1 2 3 4 5 n/a

Meeting Deadlines 1 2 3 4 5 n/a

Effective Communication 1 2 3 4 5 n/a

Leadership 1 2 3 4 5 n/a

Teamwork 1 2 3 4 5 n/a

Creativity 1 2 3 4 5 n/a

Initiative 1 2 3 4 5 n/a

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5/5

Commitment 1 2 3 4 5 n/a

Education 1 2 3 4 5 n/a

Experience 1 2 3 4 5 n/a