EXIT INTERVIEW

Please compete and forward directly to the Human Resource Office.

The purpose of this form is to provide information that will be used by Blinn College to improve the work environment. The second page provides the information, instructions and acknowledgments to formally close the employment relationship.

Name	Blinn ID Number

Check One: Full-time Part-time

Job Title	Department

Supervisor

Start Date	Ending Date

WAS YOUR DECISION TO LEAVE BLINN COLLEGE INFLUENCED BY ANY OF THE FOLLOWING?

Better Job Opportunity	Type of Work or Job	Relocation

Rate of Pay	Traveling Distance	Career Change

Supervision	Workload

Family Circumstances	Self-Employment

Personal Reasons	Return to School

Benefits	Working Conditions

Other (Please list)

State primary reason for leaving.

Do you feel that you understood what the job consisted of before you started?

Comment:

Did anyone train or instruct you on your duties?

Comment:

4. What did you like most about the job?

5. What did you like least about the job?

6. Do you have any suggestions for improvement or change?

Name

Forwarding and W-2 address:

City, State, Zip

Forwarding telephone number:

Forwarding email address:

Do you want this forwarding information made available to the general public? Yes No

I fully understand that all college property must be turned in and all other charges must be settled. I attest that I have properly completed any and all matters to include:

Instructional materials returned or settlement made;

Audio/Visual materials and equipment are cleared;

Flash drives, CDs, or intellectual property;

Blinn ID card(s) returned;

Parking permit returned to supervisor;

Library books have been returned or settlement paid;

All credit cards have been returned to purchasing office;

Outstanding travel advances are reconciled;

Blinn College personal & fixed asset property returned;

Uniforms returned and outstanding fees paid; and

Keys returned to the physical plant.

_______________________________________ _____________________

Signature of Employee Date

Please complete for terminating employee: ___________________________________

The following review must be completed by the applicable supervisor and returned to the Human Resource Office.

SUPERVISOR CHECKLIST ON TERMINATING EMPLOYEE

STEP	VERIFIED/ INITIAL DATE

N/A

Letter of Resignation	_________	_______	________

Termination/Resignation Form completed	_________	_______	________

Keys Returned	_________	_______	________

Parking Permit Returned	_________	_______	________

Blinn ID card(s) returned	_________	_______	________

Instructional materials returned or settlement made	_________	_______	________

Flash drives, CDs, or intellectual property	_________	_______	________

Audio/Visual materials and equipment are cleared	_________	_______	________

Uniforms returned and fees paid	_________	_______	________

Library books have been returned or settlement paid	_________	_______	________

All credit cards have been returned	_________	_______	________

(Examples: Telephone and gasoline)

Outstanding travel advances are reconciled	_________	_______	________

Blinn College personal & fixed asset property returned	_________	_______	________

(Example: cell/mobile telephones, pagers, laptop,

computers, communication radios)

Revised 8/2014

BLINN COLLEGE

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2004-08-24

Carol Lynne Estes

Blinn College