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2. 
4. EXIT SURVEY
6. We appreciate you taking time to answer all the questions of this short survey. Your individual responses are treated as confidential, and will not become part of your personnel file. We believe that the information is of vital importance and will assist in analyzing our employee retention and turnover. You may include additional comments, as we value your feedback. If you have questions or would like an appointment, call the Human Resources office at 479-621-1117. Thank you for your time and service to the City of Rogers, Arkansas!
8. First Name
9. Last Name
11. Position
12. Department*
    -- Select One --AdministrationAdult Wellness CenterAirportAnimal ServicesCommunity DevelopmentDistrict CourtFire DepartmentLibraryMuseumParks & RecreationPolice DepartmentStreet & Recycling DepartmentWater Department
14. Date of Separation
    Date of Separation
15. Job Status*

    1. Full-Time
    2. Part-Time
    3. Temporary
16. Years of Service*

    1. Less than 1 year
    2. 1 - 3 years
    3. 3 - 5 years
    4. 6 - 10 years
    5. 10 - 15 years
    6. 15 - 20 years
    7. 21+ years
18. Rate you overall job satisfaction.

    1. Excellent

    1. Good

    1. Fair

    1. Poor
20. What did you like most about your job?
22. What did you like least about your job?
24. Which of the following influenced your decision to end employment with City of Rogers? (Mark all that apply.)

    1. Lack of Advancement / Career Development
    2. Commuting Distance
    3. How You Were Treated
    4. Workload / Assignments
    5. Your Supervisor / Manager
    6. Policies / Procedures
    7. Return to School

    1. Relocation / Moving Out of the Area
    2. Benefits Package
    3. Salary / Wages
    4. Pursue a Better Opportunity
    5. Company Culture
    6. Family Circumstances
    7. Co-worker / Team Relationships
26. Before making your decision to leave, did you investigate other options that would enable you to stay?*

    1. Yes
    2. No
28. If "Yes", describe:
30. Would you recommend City of Rogers to a friend as a place to work?

    1. Yes, without reservation

    1. Yes, with reservation

    1. No
32. Rate City of Rogers - PAY / SALARY

    1. Excellent

    1. Good

    1. Fair

    1. Poor
34. Rate City of Rogers - BENEFITS PACKAGE

    1. Excellent

    1. Good

    1. Fair

    1. Poor
36. Are there any benefits you feel should be offered to City employees?
38. Rate City of Rogers - WORKING CONDITIONS

    1. Excellent

    1. Good

    1. Fair

    1. Poor
40. Rate City of Rogers - TRAINING & DEVELOPMENT

    1. Excellent

    1. Good

    1. Fair

    1. Poor
42. Rate City of Rogers - JOB ASSIGNMENTS

    1. Excellent

    1. Good

    1. Fair

    1. Poor
44. Rate City of Rogers - CONCERN FOR EMPLOYEE WELL-BEING

    1. Excellent

    1. Good

    1. Fair

    1. Poor
46. Rate City of Rogers - COMMUNICATION WITH EMPLOYEES

    1. Excellent

    1. Good

    1. Fair

    1. Poor
48. How often did your supervisor demonstrate fair and equal treatment to staff?

    1. Always

    1. Sometimes

    1. Never
50. Did your supervisor resolve staff complaints and grievances?

    1. Always

    1. Sometimes

    1. Never
52. When did your supervisor request staff feedback?

    1. Always

    1. Sometimes

    1. Never
54. How often did your supervisor schedule staff training or development activities?

    1. Always

    1. Sometimes

    1. Never
56. How frequent was your supervisor's communication style professional and easy to understand?

    1. Always

    1. Sometimes

    1. Never
58. When did your supervisor miss opportunities to recognize staff contributions or achievements?

    1. Always

    1. Sometimes

    1. Never
60. Did your supervisor regularly evaluate your performance fairly?

    1. Always

    1. Sometimes

    1. Never
62. When did your supervisor attempt to boost staff morale and team work?

    1. Always

    1. Sometimes

    1. Never
64. Thank you for completing the survey! Please include additional comments in the space provided below.
68. Consent for Release of Employment Information
    I hereby authorize City of Rogers to release any information regarding my services, attendance and character while employed at the facility to an employer with whom I subsequently apply for a job. Further, I do hereby unconditionally release City of Rogers from all liability for any damage whatsoever which might result from furnishing same.
70. DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE CONSENT STATEMENT.
    I certify that I have read, fully understand and accept all terms of the foregoing Consent Statement.
72. Signature*
73. Date*
    Date
Leave This Blank:


75. 1. Receive an email copy of this form.
76. Email address

    This field is not part of the form submission.

77. Submit

* indicates a required field