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1. Employee Name (First and Last):
(Required.)

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2. Employee Number:

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3. Market:
(Required.)

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4. Store:
(Required.)

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5. Department:
(Required.)

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6. Role
(Required.)

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7. What does your new employment opportunity offer that encouraged you to accept that company’s opportunity and leave this company?

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8. What do you think you will enjoy most about your new position?

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9. What do you value about this company?

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10. What did you like most about your job?

All Separations:

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11. How do you feel about company leadership on all levels (departmental, store, and directional team)?

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12. Was a single event responsible for your separation from the company? If so, please describe what happened.

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13. What was your relationship like with your supervisor? Your co-workers?

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14. What are the qualities and skills we should seek in your replacement?

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15. Do you have any recommendations regarding our compensation, benefits, and other reward and recognition efforts?

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16. What would make you consider working for this company again in the future? Would you recommend the company as a good place to work to your friends and family?

Please rate the following questions on a scale of 1 – 5 with 1 - STRONGLY DISAGREE, 2 - SOMEWHAT DISAGREE, 3 - NEUTRAL, 4 - SOMEWHAT AGREE and 5 - STRONGLY AGREE:

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17. I knew what was expected of me at work.

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18. I had the tools and resources I needed to do my job.

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19. At work, I had the opportunity to do my best every day.

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20. In the last seven days, I have received recognition or praise for doing good work.

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21. My supervisor, or someone at work, seems to care about me as a person.

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22. There is someone at work who encouraged and guided my development.

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23. At work, my opinions seemed to count.

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24. The mission or purpose of my company made me feel my job is important.

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25. My associates or fellow employees are committed to doing quality work.

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26. I have a mentor or friend at work.

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27. In the last seven days, someone at work has talked to me about my progress.

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28. At work, I felt I had the opportunity to learn and grow.

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29. Additional Comments:

T