[{"id":"cb6c1777-6b0f-4ea1-865c-e3539428c04c","order":10,"text":"EXIT INTERVIEW & SEPARATION DOCUMENTATION FORM","fontSize":"20","textAlign":"center","bold":true,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"b7f3c1e8-4957-4f0c-9dcc-aa7804dcc034","order":20,"text":"Confidential Human Resources Record","fontSize":"14","textAlign":"center","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"c410fd6b-8343-427a-b53b-831cd37de3c3","order":30,"text":"This form documents the exit interview and separation of [Employee full name] (the “Employee”) from [Company / employer name] (the “Company”). It records the Employee’s feedback and memorializes information relevant to the Company’s legal, compliance, and human-resources obligations. It is prepared in the ordinary course of business and is intended to be maintained as a confidential personnel record with restricted access.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"37baf23b-42ff-436c-93fa-75aad7ea4b67","order":40,"text":"Employee and Position","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10"},{"id":"49d8f8fd-ea52-4762-b7f3-1385143ea66e","order":50,"text":"Employee: [Employee full name] | Employee ID: [Employee ID]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"d6079c5c-aea5-425b-bf63-d8c87333fd9a","order":60,"text":"Job title: [Job title] | Department: [Department]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"c894d7b1-b85e-42c4-b390-89b750093b2e","order":70,"text":"Manager / supervisor: [Manager / supervisor]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"1b4cfc55-cb2c-438d-b1b2-101851c39cf6","order":80,"text":"Hire date: [Hire date] | Last day worked: [Last day worked]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"8f77f25a-5b99-49fd-8faf-09f2c1bab491","order":90,"text":"Separation Classification","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"8803d21d-a1ca-47bf-8ca3-7f10822495a0","order":100,"text":"The Company classifies this separation as: [Type of separation].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"79755049-cd33-488b-ba55-210b315d766d","order":110,"text":"This form does not alter the at-will nature of the employment relationship. Unless a separate written agreement signed by an authorized representative of the Company provides otherwise, the Employee’s employment was at-will and could be terminated by either party at any time, with or without cause or notice.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"d9a5eb76-77e6-4617-9e66-f0a4a7df12aa","order":120,"text":"Reason for Departure","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"ece29ccb-39a3-45a6-9062-8aae433e296d","value":"an involuntary termination","type":"remove","operator":"="},{"field":"ece29ccb-39a3-45a6-9062-8aae433e296d","value":"a layoff or reduction in force","type":"remove","operator":"="}]},{"id":"19313bbd-6fff-4dc1-94a8-1b973835cb4e","order":130,"text":"The Employee states the following reason(s) for leaving: [Stated reason for leaving]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"ece29ccb-39a3-45a6-9062-8aae433e296d","value":"an involuntary termination","type":"remove","operator":"="},{"field":"ece29ccb-39a3-45a6-9062-8aae433e296d","value":"a layoff or reduction in force","type":"remove","operator":"="}]},{"id":"89f1f89d-fb5e-427f-82f0-d5d3aed343b8","order":140,"text":"Has the Employee accepted another position? [Accepted another position].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"ece29ccb-39a3-45a6-9062-8aae433e296d","value":"an involuntary termination","type":"remove","operator":"="},{"field":"ece29ccb-39a3-45a6-9062-8aae433e296d","value":"a layoff or reduction in force","type":"remove","operator":"="}]},{"id":"5f88eadf-4b98-4bb9-b071-93aa1fa91243","order":150,"text":"Subsequent employer (as voluntarily disclosed): [New employer (if disclosed)].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"displayConditions":[{"field":"ece29ccb-39a3-45a6-9062-8aae433e296d","value":"an involuntary termination","type":"remove","operator":"="},{"field":"ece29ccb-39a3-45a6-9062-8aae433e296d","value":"a layoff or reduction in force","type":"remove","operator":"="},{"field":"d74fd11e-90c4-4434-a0eb-a25bca4a950e","value":"did not accept another position","type":"remove","operator":"="}]},{"id":"a4f3425e-b292-454b-a16e-985943e54187","order":160,"text":"Basis for Separation","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"ece29ccb-39a3-45a6-9062-8aae433e296d","value":"a voluntary resignation","type":"remove","operator":"="},{"field":"ece29ccb-39a3-45a6-9062-8aae433e296d","value":"a retirement","type":"remove","operator":"="},{"field":"ece29ccb-39a3-45a6-9062-8aae433e296d","value":"the conclusion of a fixed-term or contract assignment","type":"remove","operator":"="}]},{"id":"2715a6c1-578b-4d59-8d74-56dfd10f6e9d","order":170,"text":"The Company records the following non-discriminatory, legitimate business basis for the separation: [Stated basis for separation]. The Employee was given an opportunity to respond and to provide the Employee’s own account during this interview.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"displayConditions":[{"field":"ece29ccb-39a3-45a6-9062-8aae433e296d","value":"a voluntary resignation","type":"remove","operator":"="},{"field":"ece29ccb-39a3-45a6-9062-8aae433e296d","value":"a retirement","type":"remove","operator":"="},{"field":"ece29ccb-39a3-45a6-9062-8aae433e296d","value":"the conclusion of a fixed-term or contract assignment","type":"remove","operator":"="}]},{"id":"57bc172f-3464-489c-a5a7-47023a8cc445","order":180,"text":"Exit Feedback","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"0b9423a6-9610-4bb4-a8ea-d9c407ab03f1","order":190,"text":"The Employee provided the following feedback. Ratings are recorded on a scale of 1 (very dissatisfied) to 5 (very satisfied).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"785e504b-2f35-45b3-90e4-b2ad1c72ead7","order":200,"text":"Role and responsibilities: [Role satisfaction] | Compensation and benefits: [Compensation and benefits satisfaction]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"0f826b48-f5e0-4e7a-ba43-733e01d38d8b","order":210,"text":"Management and supervision: [Management satisfaction] | Workplace culture: [Workplace culture satisfaction]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"23c7da67-d768-4357-a3ec-a0c1ca25886b","order":220,"text":"Would the Employee recommend the Company as a place to work? [Would recommend the Company].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"2a199cf7-ccb0-4435-a065-ab41298cc657","order":230,"text":"Additional comments provided by the Employee: [Open feedback]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"375af455-448f-4756-b6ea-4355ae6a6f2b","order":240,"text":"Legal and Compliance Risk Documentation","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"16f8d319-9a18-45aa-a86f-97347262093a","order":250,"text":"During this interview, the Employee was asked whether the Employee wished to raise any concern relating to harassment, discrimination, retaliation, wage and hour matters, workplace safety, or any other legal or ethical issue. The Employee identified the following: [Concerns raised].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"514c68da-d1e2-4e44-aa91-f6e70afb9df5","order":260,"text":"Description of any concern(s) raised, in the Employee’s own words to the extent provided: [Description of concerns raised]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"a44d288c-fde8-4641-be5f-725871fc4373","order":270,"text":"The Employee was asked whether any complaint, charge, grievance, claim, or investigation involving the Employee remains pending or unresolved: [Pending or unresolved complaint].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"27670826-c681-42f9-9588-d7ed3557e257","order":280,"text":"Details of any pending or unresolved matter: [Description of pending complaint].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"56704f33-37ab-4855-845a-04e87ca6f9f8","value":"Yes","type":"add","operator":"="}]},{"id":"ca101708-98ee-43ec-b518-83670f8b3c0c","order":290,"text":"Nothing in this form, and nothing said during the exit interview, waives, releases, or limits any right the Employee may have, including the right to file a charge or complaint with, or to participate in an investigation by, the Equal Employment Opportunity Commission, the National Labor Relations Board, the Department of Labor, or any other federal, state, or local agency, or to report possible violations of law to any governmental agency or self-regulatory organization.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"54aaa2de-177d-4932-ab67-fbd39ced9856","order":300,"text":"Return of Company Property","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"3e785ba2-0409-4361-bdba-381ed43ec39c","order":310,"text":"Has the Employee returned all Company property, including keys, access cards, credit cards, equipment, devices, documents, and data? [Company property fully returned].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"f5e6096c-704d-48fd-8170-ab36f81b40b0","order":320,"text":"Outstanding items to be returned, if any: [Outstanding company property]. The Employee agrees to return any outstanding Company property promptly.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"displayConditions":[{"field":"e4b1441b-7492-449b-9768-35e4c4456893","value":"Yes, all property has been returned","type":"remove","operator":"="}]},{"id":"3e8538bf-4c28-4df0-9443-7b664aab60d0","order":330,"text":"Final Pay and Benefits","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"6da741c2-e057-410f-a143-9ee13e3eedb4","order":340,"text":"The Employee’s final paycheck will be issued on or about [Final paycheck date], in accordance with applicable state law governing timing of final wages. Payout of accrued but unused paid time off or vacation, where required by law or Company policy: [Accrued PTO / vacation payout].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"35f6dfa5-1cda-4014-9816-12cc5ad1ca16","order":350,"text":"Continuation of group health coverage under COBRA (or applicable state continuation law) was explained, and required notices will be provided: [Benefits continuation (COBRA) reviewed].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"59ea3956-5185-49b8-a295-707d14c4de43","order":360,"text":"Continuing Obligations","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"7d3afd9e-1690-4075-a367-be6a778da599","order":370,"text":"The Employee was reminded that any confidentiality, non-disclosure, assignment-of-inventions, and intellectual-property obligations owed to the Company survive the end of employment in accordance with their terms and applicable law. The Employee must not retain, use, or disclose the Company’s confidential or proprietary information or trade secrets.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"dfdca0f0-cdc6-4455-a028-5d5170b5337e","order":380,"text":"The Employee was reminded of any post-employment obligations that remain enforceable under applicable law, which may include obligations not to solicit the Company’s employees or customers. The enforceability of any non-competition or non-solicitation covenant is governed by the law of the State of [Governing state], and nothing in this form expands any such obligation beyond what that law permits.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"c74f03dd-4389-4363-8dea-c6695bd15e69","order":390,"text":"This form is not a release of claims and is not a severance agreement. Any release of claims, severance, or non-disparagement undertaking must be set out in a separate written agreement that complies with applicable law, including, where applicable, the Older Workers Benefit Protection Act.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"48d6f5e0-d12c-4e17-9dda-af1525e65d6e","order":400,"text":"Acknowledgment","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"17674336-0c21-4c2f-987f-b1749b6ad107","order":410,"text":"The Employee acknowledges that the Employee participated in this exit interview, that the feedback recorded reflects the Employee’s statements, and that the Employee was given the opportunity to raise concerns. The Employee’s signature does not constitute agreement with the Company’s classification of the separation and does not waive any right or claim. The Company maintains this record confidentially.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"0ed51532-29a7-425e-b589-3cc7ff333496","order":420,"text":"Employee","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"f3a67cc7-2119-4c83-9f20-84432bbb5f04","order":430,"text":"Signature: ______________________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"647094bc-9c09-42ce-b01d-774e18baa40e","order":440,"text":"Name: [Employee full name]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"7052ddf0-3f16-4e03-9e3e-c7c519c2eca2","order":450,"text":"Date: [Date signed]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"9cb19639-c796-4ef9-9d5b-48aa8791ad10","order":460,"text":"Company Representative","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"ccf5309e-7ab4-473d-b0cf-0372e2a29e79","order":470,"text":"Signature: ______________________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"9c006796-0bce-4757-9193-323a5eb37f4e","order":480,"text":"Name: [Interviewer name] | Title: [Interviewer title]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"7a1bac8f-cb0e-494a-bc14-ffb12bd437b8","order":490,"text":"On behalf of: [Company / employer name]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"029a25d3-460f-4a76-ab7d-167e2037780a","order":500,"text":"Date: [Date signed]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"6ce49f0d-f333-4729-89c9-81faacaa22da","order":510,"text":"This record was completed by [Interviewer name] for and on behalf of [Company / employer name] on [Last day worked], and is retained as a confidential personnel record under the records-retention and privacy policies of [Company / employer name].","fontSize":"11","textAlign":"left","bold":false,"underline":false,"marginBottom":"0","cflou":false,"active":true}]