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* 1. Employee Name

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* 2. Job Title

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* 3. Immediate Supervisor

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* 4. Last Day Worked

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* 5. County you worked in:

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* 6. Please choose:

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* 7. Explain your reason for leaving:

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* 8. What did you like most about working at CRSI?

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* 9. What did you like least about working at CRSI?

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* 10. What recommendations would you suggest for improvement?

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* 11. How would you rate the following aspects of your employment?

  Excellent Good Fair Poor
Training
Advancement Opportunities
Performance Reviews
Work Environment
Pay
Benefits
Schedule/Hours

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* 12. How would you rate your supervisor in the following areas?

  Excellent Good Fair Poor
Shows fairness
Provides recognition
Solves problems promptly
Follows policies and procedures
Communicates effectively with staff
Encourages suggestions/feedback

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* 13. Were you satisfied with the working relationship you had with your coworkers?

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* 14. What could we have done to prevent you from leaving?

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* 15. Comments/Suggestions?

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