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The information submitted on this form is strictly confidential
Full name (optional)
Date of leaving (dd/mm/yyyy)*
Length of service in final post
Leaver or internal transfer?*
Overall length of service
What is the main reason for leaving
PromotionBetter Terms and ConditionsBetter Staff Benefits and Rewards packageBetter Working Conditions/Flexible WorkingBetter Prospects for Career ProgressionPoor Working RelationshipsNearer HomePersonal/domestic reasonsFurther EducationTemporary Employment EndedHealth ReasonsDid Not Return From Maternity LeaveRetirementRedundancyOther (please specify below)
Please provide more details on the reason/s given above
The following questions relate solely to your experience in your most recent job
What aspects of the job were most rewarding and why? (e.g. colleagues, environment, patient contact)
What aspects of the job were least rewarding and why?
Are there any aspects of this job which you would change to enable your role to be more effective? (Please identify why)
How would you describe your working relationship with your line manager?*
How would you describe your working relationships with your colleagues?*
Please use this space to expand on the previous two questions if needed
The following questions relate to your overall experiences and opinions of the Trust as an employer
What were the positive aspects of your employment with the Trust/YTHFM??
What were the negative aspects of your employment with the Trust/YTHFM??
What could have been done to improve your experience of working for the Trust/YTHFM:
By your colleagues?
By your line manager?
Head of service or senior manager?
Overall, did you enjoy working for the Trust/YTHFM?
Would you consider re-employment by the Trust/YTHFM in the future? (Please select the likelihood with 0 being ‘very unlikely’ and 10 being ‘’very likely’)*
May we share the information on this questionnaire with your line manager?*
Would you like to discuss your answers personally with a representative from the Human Resources department?*
If yes, please provide a phone number or email address we can contact you on
Please support our work to reduce inequalities amongst staff, by completing the below:
Sex and gender – which of the following best describes you?*
FemaleMaleNon-BinaryOtherPrefer not to say
Is your gender identity the same as the sex you were assigned at birth?*
YesNoPrefer not to say
16-2021-3031-4041-5051-6566+Prefer not to say
Ethnicity - choose one option that best describes your ethnic group *
ArabAsianBlackMultiple / MixedWhiteOtherPrefer not to say
Sexual orientation *
AsexualBisexualGay or LesbianHeterosexual or StraightOtherPrefer not to say
What is your religion? *
BuddhistChristianHinduJewishMuslimSikhNoneOtherPrefer not to say
Health - do you have any physical or mental health conditions or illnesses lasting or expected to last for 12 months or more?*
If yes, has the Trust / YTHFM made reasonable adjustments to enable you to carry out your work?
YesNoNo adjustments required
If yes, please share any information you are comfortable to, e.g. whether the adjustments have been effective / what else could have been considered
Caring responsibilities - do you have any children aged from 0 to 17 living at home with you, or who you have regular caring responsibility for?*
Do you look after, or give any help or support to family members, friends, neighbours or others because of either: long term physical or mental ill health / disability, or problems related to old age?*
If you have any caring responsibilities has the Trust / YTHFM made reasonable adjustments to enable you to balance your work and caring commitments?
If yes - please share any information you are comfortable to, e.g. if you have a child with additional needs, and about whether the support to balance your caring responsibilities has been effective / what else could have been considered
If there are any other comments you would like to make about support needed / provided in relation to protected characteristics – please include them below:
Thank you for taking the time and effort to complete this questionnaire. This will be retained for a period not exceeding six months and will be destroyed.
* required fields
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