Exit Interview Checklist

Instructions:

This form is to be completed by the supervisor or department representative before an   employee’s last date of employment at XXX. Place a check in the box after each item has been returned. If a particular item does not apply, write N/A to the left of the box. After you    have completed this form, sign it and return it to YYY.  It will be placed in the employee’s personnel file.

Employee Name: ______________________________________ Date: _____/_____/_____

Department: ___________________________   Supervisor: _________________________

Position: __________________  Dates of Employment:  From: ___/___/___ to___/___/___

Where to send W-2: _________________________________________________________

The following items have been returned:

 Keys

 Company Equipment/Laptop Computer

 Company Credit Card

 Cellular Phone

 Company Documents

 Other Company Property

 ID Card

 Uniform

 Other: _________________________________________________________________

Comments:  _________________________________________________________________________

I verify that all the items checked above have been accounted for.

Supervisor Signature_____________________________________ Date ____/____/____