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* 1. Associate's Name:

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* 3. Position:

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* 4. Direct Supervisor:

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* 5. Last Day of Work:

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* 6. What was your primary reason for leaving AFC Urgent Care?

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* 7. Add on: Were there any other contributing factors in your decision?

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* 8. Are you comfortable sharing where you’ll be working in the future and the position title?

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* 9. Add on: What about your future employer made the opportunity attractive for you?

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* 10. If you could have changed anything about your job or the company, what would you change?

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* 11. Is there anything we could have done to keep you employed with AFC Urgent Care?

On a scale of 1-5 (1 being worst and 5 being best), please rate the following:

*If response is rated as a ‘1’ or ‘2’, please capture specific comments in Additional Comments section below.

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* 21. Additional Comments:

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