University Hospital Employee Exit Interview Meeting Form

Please complete the Interview Meeting Form. Once completed, form data will be sent to Renae Rokicki, Organizational Training and Development (OTD). Once Exit Interview Meeting form is received, the resigning employee will be contacted within three days to finalize an exit interview date.

Name of resigning employee (non-RN):	Last Name: First Name:
Employee ID#:
Employee Job Title:
Date of Resignation:	mm/dd/yyyy
Last Day of Employment (date)	mm/dd/yyyy
Your E-Mail address: (ex.: bradyl@upstate.edu)
Your Department/Unit:
Primary Shift:
Best way to reach resigning employee to schedule exit interview:	(please list phone number or state 'email')
Manager's Name: