Interview Manual
Transcript of Interview Manual
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Executive Interview Summary
The Executive Interview Summary is designed for evaluating candidates
for executive, administrative and professional positions. Like the
Employment Interview Report it provides the means for you to
systematically record your opinions regarding the candidates suitability for
placement. Use of this form enables you to rate every aspect of past work
experience, including supervisory skills and many other factors which affect
job performance, such as adaptability, creativity, initiative, perseverance,
etc. The interviewing to make sure all the pertinent aspects of the
candidates background are covered.
As the interviewer, you not only know the candidates record, but you havesome understanding of the candidates behaviour. What could you learn after
spending approximately one hour or so with the candidate? Someone who
reads an employment application can determine if the candidate is a hard
worker, an initiator, achievement oriented, and disciplined. You, as the
interviewer can assess the candidates sincerity, confidence and tact.
Name of applicant ______________________________________ Date ____________
Position applied for _________________________________ Reference _____________
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INTERVIEW GUIDE
Notes: ______________________________________________________
This interview guide has been designed to help selection of employees by
making each interview more objective. Additional questions will be asked
during the interview and answers to them can be recorded.
Statements in italics are to assist the interpretation of answers and may
suggest additional areas to probe. Although answers will have been notedduring the interview, the guide should be reviewed and answers expanded on
afterwards. The interview should be summarised by completing the
interview Report.
The applicant will want to know details about the job, the benefits, prospects
and so on, and ample opportunity should be allowed for these questions to
be asked and answered.
This form should be used in conjunction with the Application for
Employment form, since certain questions will be varied according to
information which has been already given by the applicant.
EDUCATION
1. How will your education help you to be successful in the job for which
you are being considered ?
2. Describe any part-time work you did during your time at school ?
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3. What courses did you like best ? ________________________________
4. What courses did you like least ? ________________________________
5. Were your results average, below average or above average ?
Can you give me more details on this ? ___________________________
6. Have you continued your education in any way since leaving school ?
__________________________ if yes, how ?
7. Have you had any special training courses in connection with any of your
Jobs ?
______________________________________________________
If yes describe ______________________________________________
Or describe any special training you may have received in connection
with any of your jobs _________________________________________
attitude to company training ?
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EMPLOYMENT
1. Describe in detail the kind of work you did in your present/last job.
Give briefer descriptions of your previous jobs
Will previous experience help in job applicant is being considered for ?`
Has each change been to a better and more responsible job ? If unemployed, at anytime, find out reasons why.
2. How did you obtain each job ? __________________________________
self reliant ? Resourceful ? Creative in approach ?
3. What salary increases or promotions did you receive ? _______________
Were they based on good work ? Was advancement quicker than others ?
4 (a) May we contact your former employers for references ?
(b) Has a former employer ever refused to give you a recommendation ?
5. What experience have you of handling people? Supervising others ?
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Evidence of good relations with people ?
6. What did you like best about your past jobs ? What did you dislike most?
_____________________________________________________________
______________________________ is there justification for dislike?
7. Give more details on why you are leaving / have left your job and why
you left previous jobs
Are answers reasonable and consistent ?
8. Describe the criticism most often made of your work by your employers
Welcomes constructive criticism ? Objective about self ? Serious attitude to
the work ?
9. What do you believe are your strongest qualities ?
10.Are you satisfied with your work progress up till now ?_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
establish reasons.
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11.Why do you want to work for this company and what attracts you to this
Job and what do you know about our company ?
___________________________________________________________
Are reasons satisfactory ? Is candidates estimate of value to us realistic ?
Can we satisfy needs ?
FINANCIAL
1. Have you ever held a part-time job to supplement the income from your
full-time job ? _____________________________________________
If yes, describe the type of work _______________________________
2 (a) What position do you want to hold 10 years from now ?
(b) How do you plan to achieve these goals ?
_____________________________________________________________
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PERSONAL AND SOCIAL
1. In what school/college/university (use whichever is appropriate)
activities eg. Clubs, sports etc. did you participate ?
__________________________________________________________
What motivated participation ?
2. What offices or positions did you hold in these clubs or organisations ?
Was there any desire to lead ?
3. What did you do during holiday/vacation periods when you were a
student?
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Was activity purposeful ?
4. What part have you taken in your clubs or Organisations ?
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Evidence of leadership or organising ability ?
5. What kind of books and periodicals do you read ?
Wide breadth of subjects ?
6. What illnesses, accidents or operations have you had during the past tenyears ?
___________________________________________________________
Good health generally ?
Only ask questions 7 & 8 if candidate has answered YES to disability
questions on the Application Form.
7. Describe your physical disability ________________________________
8. Would you be able to perform the job in spite of your disability ? What
additional help or facilities would you require ?
___________________________________________________________
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OTHER QUESTIONS
To : _______________________
From : ______________________
EMPLOYMENT INTERVIEW REPORT
Name of applicant : ____________________ Date of this interview : ______________
Address : ______________________ Phone ____________ 1st interview
Candidate for : ____________________________________ This is 2nd interview
Interviewer : ______________________________________ 3rd interview
Indicate your impressions gained from interviewing applicant by ticking
appropriate box under each heading. Assess each quality in relation
to position candidate has applied for :
1. APPEARANCE
Very untidy Somewhat Satisfactory Neat and tidy, unusually well
Careless about personal better than groomed and
Personal appearance average very neat.
Appearance appearance
2. FRIENDLINESS
Appears very Reserved Approachable Warm, friendly Extremely
distant and fairly friendly sociable friendly veryaloof warm and
outgoing
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3. POISE
Ill at ease, jumpy Somewhat tense Reasonably at Self assured Extremely well
And very nervous easily irritated ease composed
4. PERSONALITY
Unsatisfactory Doubtful Average and Very good, above Outstanding
Satisfactory average excellent all
round.
5. CONVERSATIONAL ABILITY
Talks very little Hesitant, lower Average fluency Talks well and Excellent
Poor expression than average and expression does not waste expression
Fluency and words extremely fluent
6. ALERTNESS
Very slow to grasp Rather slow Grasps ideas with Quick to Exceptionally alert
Ideas requires more average speed understand understands new
Than average perceives well ideas instantlyExplanation
7. KNOWLEDGE OF WORK FIELD
Poor, no Limited Average Well informed Excellent
Appropriate knowledge knowledge not knowledge knowledge with
Knowledge at all covering some covering all covers all areas faultlessAreas areas fully coverage
8. QUALIFICATIONS
Not relevant to job Some relevance Satisfactory, as Very suitable Ideal for job
To job good as might be for job perfect matchExpected
9. SKILL
None appropriate Some skill in job Reasonable Well skilled in Excellent skills
Area amount, average area ideal for job
for job
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10. EXPERIENCE
No relation Some experience Average, Well skilled in Excellent skillsBetween in relevant area background job area ideal for job
Background and covers jobJob requirement area
11. DRIVE AND
INITIATIVE
Poorly defined Makes little effort Average effort High desire to Sets high goals
Goals, acts to achieve goals some initiative achieve, strives always takes
without purpose hard. Initiative
12. OVERALL
Unsatisfactory Below standard Average Above average Outstanding
But just higher than
Acceptable requiredStandard
The applicant should be offered the job
Considered for further interview
Placed on reserve list
Rejected
Signature of interviewer _________________________________________________________________
Reasons and comments ___________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
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EMPLOYMENT INTERVIEW SUMMARY
For Executives, Administrative, and Professional Personnel
Candidate Name ___________________________________________________________________
Information
Address _________________________________ Telephone _______________________
Position applied for ________________________________________________________
Date of Interview ___________________ Place of interview _______________________
Purpose of To record the interviewers opinions as to the candidates suitability for placement within
This the organisation.Employment
InterviewSummary
Overall The interviewers overall evaluation of the candidate should be based on the detailed
Evaluation evaluation contained herein, and should be summarised below after the completion of the
Of the interview.
candidate
Recommended Not recommended for
______________________________________________________ because
Position
Prepared by: Interviewers name _____________________ Title _____________________________
Signature __________________________________________ Date ________________
Instructions for Sections A, B and C require rating the candidate on characteristics usually pertinent
Sections A,B, to job performance of executive, administrative and professional personnel. Omit any
And C characteristic(s) you consider unrelated to the position for which the candidate is being
Considered. For each characteristic, rte the candidate poor, fair, average, good or
Excellent using these rating definitions and check the appropriate box.
Poor
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EMPLOYMENT INTERVIEW SUMMARY
For Executive, Administrative and Professional Personnel
Candidate Name ____________________________________________________________________
Information
Address __________________________________________________________________
_______________________________________ Telephone _________________________
Position applied for _________________________________________________________
Date of Interview ___________________ Place of Interview ________________________
Purpose of To record the interviewers opinions as to the candidates suitability for placement withinthis the organisation.Employment
Interview
Summary
Overall The interviewers overall evaluation of the candidate should be based on the detailed
Evaluation evaluations contained herein and should be summarised below after the completion
Of the of the interview.candidate
Recommended Not recommended for
_____________________________________________________ because
Prepared by : Interviewers name ________________________ title ___________________________
Signature __________________________________ Date ________________________
Instructions for Sections A, B and C require rating the candidate on characteristics usually pertinent to
Sections A,B, job performance of executive, administrative and professional personnel. Omit any
and C characteristic(s) you consider unrelated to the position for which the candidate is being
considered. For each characteristic, rate the candidate poor, fair, average, good or
excellent using these rating definitions and check the appropriate box.
Poor : Definitely below acceptable standards, performance of job requirementsProbably will be consistently deficient.
Fair : Improvement is needed to meet acceptable standards, performance
of job requirements probably will be inconsistent.
Average : Meets acceptable standards, consistent performance of job requirements
predicted.
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Good : Above acceptable standards, performance usually should exceed job
requirements.
Excellent : Outstanding unquestionably above acceptable standards, probably
performance will consistently exceed job requirements.
Two common mistakes in rating are: (1) A tendency to rate nearly everyone as
average on every characteristic instead of being more critical in judgement. Theevaluator should use the ends of the scale as well as the middle (2) The halo effect i.e.
a tendency to rate the same individual excellent on every characteristic or poor on
every characteristic based on the overall picture one has of the person being evaluated.
However, each candidate has strong and weak points and these should be indicated on
the rating scales.
In addition to your rating, for each characteristic, cite evidence from the candidates work
History and / or employment interview to back up your rating.
SECTION A
Work
Performance Poor Fair Average Good Excellent Knowledge Understanding of fundamentals
Skills, methods and procedures required in
Job Reasons (s) for your rating :
Planning Development of methods and work
Organisation to efficiently perform overall
Work load
Reasons(s) for your rating :
Application Ensure consistent job performance
To complete overall work load.
Reasons(s) for your rating :
Thoroughness Attentionto requisite detail
To completeness, avoidance of superficiality
Reason (s) for your rating :
SECTION BPoor Fair Average Good Excellent
Supervisory
Performance
Organisation Division of total operation
into efficient independent components
Reason (s) for your rating :
Personnel selection identification of job
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required characteristics in prospective
employees
Reason (s) for your rating :
Training Development of personnel
Efficiency,Reason(s) for your rating :
Follow-Up Monitoring that instructions
Schedules etc. are being followed
Reasons(s) for your rating :
Economy Minimisation of controllable
Costs, optimum utilisation of resources
Reason (s) for your rating :
Leadership Establishment of
Personnel team effort toward common
Objectives.
Reason (s) for your rating :
Poor Fair Average Good Excellent
SECTION C
Factors Affecting
Job Performance
Adaptability Alteration of activities
Plans etc. to accommodate new or
Changed situations. Reason (s) for your rating :
Analysis Examination of a problem
leading to identification of its
component parts and their relations
Reason (s) for your rating :
SECTION C
Factors Affecting
Job Performance
(continued) Poor Fair Average Good Excellent
Cooperation Working effectively
with others to achieve common
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goals.
Reason(s) for your rating :
Creativeness improvement of
Methods, procedures, etc. by
new ideas.
Reason (s) for your rating :
Education Jobrelatedness of
Candidates education.
Reason(s) for your rating :
Expression Oral presentation
of ideas.
Reason (s) for your rating
Initiative Self confident,Enthusiastic, performance
of a task with a minimum
of instruction.
Reason (s) for your rating
Judgement Formation of a
Sound opinion by careful
Study of available facts andOptions.
Reason (s) for your rating
Perseverance Maintenance
of position in spite of opposition
or discouragement.Reason(s) for your rating.
Reliability Dependability, instills
full confidence.
Reason(s) for your rating.
OVERTIME REQUEST AND APPROVAL
Date __________________________________________________________________________________
Request employee _______________________________________________________________________
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Payroll or time clock No ______________ Dept _________________ Shift
_________________________
Be permitted to work ___________________________ hours on ___________________ (Date)
Overtime Make up time
On Job No. ____________________________________________________________________________
Describe ______________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Reason for request ______________________________________________________________________
______________________________________________________________________________________
Request prepared by ________________________________________________________(Signature)
Approved/Refused by _______________________ (Signature) Date ______________________________
Reason ________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Delete word not applicable
Name ____________________________________ Date _____________________
Job title _____________________ Department _____________________________
(Prepare in duplicate)
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HOLIDAY REQUEST
Years service _____________________ Holiday entitlement ______________________
To assist in scheduling holidays, please indicate your first, second, and third choice
below and return both copies of this form to __________________ by ______________One copy will be returned to you indicating your approved holiday dates.
First choice Second choice Third choice
1st period From ________________ From ______________ From ________________
To ________________ To ______________ To ________________
2nd period From ________________ From ______________ From ________________
To ________________ To ______________ To ________________
3rd period From ________________ From ______________ From ________________
To ________________ To ______________ To ________________
4th period From ________________ From ______________ From ________________
To ________________ To ______________ To ________________
5th period From ________________ From ______________ From ________________
To ________________ To ______________ To ________________
Signature : ________________________________ Date : ______________________
The following dates for your holiday have been approved
1st period From ______________________ To ____________________________
2nd period From ______________________ To ____________________________
3rd period From ______________________ To ____________________________
4th period From ______________________ To ____________________________
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5th period From ______________________ To ____________________________
Signature : ________________________________ Date : ______________________
NEW EMPLOYEE DATA CARD In case of emergency notify
Name ______________________________ Name _______________________
IC No. ______________________________ Address ______________________
_____________ Tel No. __________
ADDRESS : _________________________________________________________________________
Present address _______________________________________ Telephone No. ___________________
Previous address ______________________________________ Telephone No. ___________________
How long have you lived at your present address ____________________________________________
How long at previous address ____________________________________________________________
PERSONAL
Date of birth ___________________Sex Male/Female ___________ Height _________ Weight ________
Marital
Status Single Married Engaged Separated Divorced Widowed Date of marriage
Name of spouse _____________________ Where employed _____________________________________
Dependent children (Names and ages)
Number of dependants including yourself ____________________________________________________
Name and address of next of kin if other than spouse ___________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Do you possess a driving licence ? __________________________________________________________
Have you been convicted of a crime in the past ten years, excluding misdemeanors and summary offences?
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If yes, describe in full ____________________________________________________________________
List any relatives working for us ___________________________________________________________
PHYSICAL/MEDICAL
Describe your general health Poor Fair Average Good Excellent
Do you have any physical or mental condition which may limit your ability to perform certain kinds ofwork?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
If yes, describe such condition (s) and specific work limitations ___________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Have you had a major illness in the past 5 years ? ____________ If yes, describe _____________________
Have you suffered any serious injuries at work ? _____________If yes, describe _____________________
Do you receive any form of disability pension in respect of such injury ? ___________________________
In respect of any other injury ? _____________________________________________________________
RECORD OF EDUCATION
____________________________________________________________________________________
School Name and address of school Course of study Years attended List certificate
From To Diploma or
Degree
____________________________________________________________________________________
Elementary X X
____________________________________________________________________________________
Secondary X
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____________________________________________________________________________________
Higher
____________________________________________________________________________________
Other(specify)
____________________________________________________________________________________
EMPLOYMENT HISTORY List below all past employment beginning with most recent
_____________________________________________________________________________________
Name and address of Company From To Weekly Weekly Reason for Name of
Mnt yr Mnt yr starting Last Leaving Supervisor
Pay Salary
______________________________________________________________________________________Describe the work you did
__________________________
__________________________
Telephone
______________________________________________________________________________________
_____________________________________________________________________________________Name and address of Company From To Weekly Weekly Reason for Name of
Mnt yr Mnt yr starting Last Leaving Supervisor
Pay Salary
______________________________________________________________________________________
Describe the work you did
__________________________
__________________________Telephone
______________________________________________________________________________________
_____________________________________________________________________________________
Name and address of Company From To Weekly Weekly Reason for Name of
Mnt yr Mnt yr starting Last Leaving Supervisor
Pay Salary
______________________________________________________________________________________
Describe the work you did
__________________________
__________________________
Telephone______________________________________________________________________________________
_____________________________________________________________________________________
Name and address of Company From To Weekly Weekly Reason for Name of
Mnt yr Mnt yr starting Last Leaving SupervisorPay Salary
______________________________________________________________________________________
Describe the work you did
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__________________________
__________________________
Telephone
______________________________________________________________________________________
The following information is merely for our records and not to enable us to make any approach to the
organisations mentioned.
If you have a current bank account, please give the name of the bank ______________________________
and the address of the branch ______________________________________________________________
_________________________________________ Account No. __________________________________
Name and address of your doctor ___________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Summarise here any additional experiences and / or skills you may have including interests pursued outside
your normal work.
List any civic, businesses or professional organisations of which you are a member.
The facts set forth above are true and complete to the best of my knowledge.
Date : ______________________ Signature : _________________________________________
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PROBATIONARY EMPLOYEE EVALUATION
RATING OF EMPLOYEE Carefully evaluate each of the qualities separately
______________________________________________________________________________________Unsatisfactory Satisfactory No rating
______________________________________________________________________________________
Quality of work
______________________________________________________________________________________Quantity of work
______________________________________________________________________________________
Attitude
______________________________________________________________________________________Personal appearance
______________________________________________________________________________________
Attendance
______________________________________________________________________________________
Dependability
______________________________________________________________________________________
OVERALL EVALUATION
Compare with other employees with the same length of service in the job.
Definitely Substandard Average Definitely Outstanding
Unsatisfactory but making above
Progress average
What steps have been taken to improve employees performance ? ________________________________
Warning (s) Details _______________________________________________________
Extra training _______________________________________________________
Diminished duties _______________________________________________________
Extra supervision _______________________________________________________
Other _______________________________________________________
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RECOMMENDATION
Do you recommend that this probationary employee be given a permanent job? Yes No
If NO, for what reasons ? _______________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Name ___________________________________________________ Date _______________________
Job title ________________________ Department ___________________________________________
National I.D card No : __________________________________________________________________
EXIT INTERVIEW
Joining date ________________ Leaving date _______________ Years service ____________________
REASON FOR LEAVING
Resignation Working conditions
Better Job Family Relocation
Illness Insufficient pay Dislike work
Inconvenient working hours Personality clash Retirement
Other _________________________________________________________________________________
______________________________________________________________________________________
Was alternative offered? YES/NO Job __________________ Dept ____________________________
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Was trial period worked? YES/NO Location _______________________________________________
Why was transfer refused ? ________________________________________________________________
NOTES
The Interviewer need continue the interview only if the person has resigned.
These questions are designed to assist in an evaluation of the true reasons for leaving and to suggest ways
of preventing this in future. Statements in italics are to assist in interpretation of answers.
SELECTION
Outline the work you have been doing _______________________________________________________
______________________________________________________________________________________
_________________________________________ Has job content been correct ?
Is it the sort of work you expected to be doing when you joined ? _________________________________
______________________________________________________________________________________
____________________________________________ Establish reasons ?
What sort of work were you doing in your previous job ? ________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
_______________________ is previous work related to current job ? Does it suggest other possibilities ?
Has the work you have been doing interested you ? ____________________________________________
______________________________________________________________________________________
____________________________________ Do answers suggest incorrect selection?
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TRAINING
Would you care to comment on any aspect of your training ?
Do not lead the interviewee into criticism or approval but try primarily to listen, intervening only to keep
to the point on the basis of what the interviewee says tick the relevant sections of the table below.
____________________________________________________________________________________Type of training Inadequate low Quality Barely Adequate Satisfactory Good Excellent
____________________________________________________________________________________
Introductory
Initial specialist
Updating
Change of
Specialisation
____________________________________________________________________________________
Note any features specially mentioned ______________________________________________________
_____________________________________________________________________________________
FINANCIAL
How do you feel about your pay ? __________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
_______________________________________ is attitude realistic ?
Do you think your pay increased sufficiently during your job ? ___________________________________
______________________________________________________________________________________
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_______________________________ Have increases been less than average ?
SUPERVISION
Did you get on well with your supervisor ? _____________________________________
______________________________________________________________________________________
______________________________________________________________________________________
__________________________________________ Establish reasons for attitude ?
Do you feel that your supervisor was good at the job ? __________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
_________________________________________ Was supervision adequate ?
How did your supervisor handle any complaints that you brought ? _______________________________
______________________________________________________________________________________
______________________________________________________________________________________
_________________________________________ Was supervisor fair ?
What sort of troubles (if any) did you have with your supervisor ? ________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________ Any evidence of poor supervision ?
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SUMMARY
Describe your overall feelings about the job and why you are leaving ______________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
__________________________ Are feelings reasonable and is stated reason true ?
Only ask the this question if there appears to be some chance of the person reconsidering decision.
Would you be prepared to remain in the job under a more satisfactory arrangement ?
What changes would you require ? __________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________ Are these reasonable ? Is the proposition workable ?
COMMENTS
Interviewers assessment of the real reasons for leaving :
________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
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_______________________________________________________________________
_
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Interviewers recommendation for future action (if required)
_______________________________________________________________________
_
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
_______________________________________________________________________
_
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Interviewers signature : ____________________________ Date : ______________________________
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PERSONNEL RECORD UPDATE
Name __________________________ Department _______________________ Date ________________
In order that we may keep our personnel records up-to-date, please show below any changes since
________________________________ Show changes only
Date of last update
_____________________________________________________________________________________
Address __________________________________________________ Phone ______________________
Marital status: Engaged _______ Married _______ Separated ______ Divorced _____ Widowed ______
Number of dependants Number of Their
Including yourself _______________ Children ____________ Ages ______________________
Does your wife/husband work ? ___________ Where ________ Emergency Phone No. _______________
Emergency contact if not married
Name __________________________ Address ______________________ Tel. No. _________________
Describe any major illness you have had since last update which might limit your effectiveness on this job
______________________________________________________________________________________
______________________________________________________________________________________
if you received compensation for injuries since last update, explain ________________________________
______________________________________________________________________________________
ADDITIONAL COURSES OR SPECIAL TRAINING
______________________________________________________________________________________
Date Where studied Name of course and brief description
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______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
New memberships in technical or professional societies _________________________________________
______________________________________________________________________________________
New professional offices or honours ________________________________________________________
_____________________________________________________________________________________
Any other changes you would like us to note _________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Employees signature : _____________________ Reviewed by : _________________________________
EMPLOYEE CHANGE OF JOB REPORT
Prepare in triplicate : 1 Personnel 2 Payroll 3 Employees Department
Please enter the following change(s) as of ____________________________________________________
Name ________________________________ Clock or payroll No : _______________________________
NIC No : _______________________________________
FROM
______________________________________________________________________________________
Job Dept. Shift Rate
______________________________________________________________________________________
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______________________________________________________________________________________
TO
______________________________________________________________________________________Job Dept. Shift Rate
______________________________________________________________________________________
REASON FOR CHANGE Is the change permanent/temporary
Hired Length of service
Re-hired Re-evaluation of existing job
Promotion Resignation
Demotion Retirement
Transfer Layoff
Merit Discharge
Redundancy in former job Leave of absence to Date
Other reason or explanation ___________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
FULL DETAILS OF ACCIDENT
Diagram and photographs should be included or attached where necessary.
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List of machines, tools and materials involved
WITNESSES
Signature Position held at time of accident Contact witness at
_____________________ _______________________________ ______________________
_____________________ _______________________________ ______________________
_____________________ ________________________________ _______________________
_____________________ ________________________________ ______________________
CLASSIFICATION OF CONSEQUENCES
Employee injury
Action _____________________________________________________________________________
________________________________________ By ________________________________________
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Cost _____________ Result ____________________________________________________________
Employee absence
Action _____________________________________________________________________________
________________________________________ By ________________________________________
Cost ______________ Result ___________________________________________________________
Machine damage
Action ___________________________________ By ________________________________________
Cost _______________ Result ____________________________________________________________
Lost time
Action __________________________________ By _________________________________________
Cost ______________ Result ____________________________________________________________
Workplace repair
Action __________________________________ By __________________________________________
Cost _______________Result _____________________________________________________________
Employees claim
Damages : action__________________ By _____________ Cost ___________ Result ______________
Nat. Ins. Action __________________ By _____________ Cost ___________Result _______________
Other : action __________________ By _____________Cost ____________Result _______________
Insurance claim
Action ______________________________________ By _____________________________________
Cost _______________ Result ___________________________________________________________
Inquiry
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Private : action ____________________________ By _________________________________________
Cost _____________ Result ______________________________________________________________
Official action ____________________________ By _________________________________________
Cost _____________ Result ______________________________________________________________
Inspection
Employer : action ________________ By ____________ Cost __________ Result __________________
Safety Rep. Action _______________ By ____________ Cost __________ Result __________________
H & S action ____________________By ____________ Cost __________ Result __________________
Other action _____________________By ____________Cost __________ Result __________________
Improvement / Prohibition notice : threatened / served date
Withdrawn/complied with date
CLASSIFICATION OF CAUSES
Employee error
Action ______________________________________________________________________________
___________________________________________ By ______________________________________
Cost estimate ____________ actual _____________ Signature _____________ Date _______________
Management error
Action ______________________________________________________________________________
_______________________________________________ By __________________________________
Cost estimate ____________ actual ____________ Signature _____________ Date _________________
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Machine or materials defect
Action ______________________________________________________________________________
_____________________________________________ By _____________________________________
Cost estimate ___________ actual ____________ Signature ____________ Date ___________________
Workplace defect
Action _______________________________________________________________________________
_____________________________________________By ______________________________________
Cost estimate ___________ actual ____________ Signature _____________Date ___________________
Safety appliance defect/misuse
Action _______________________________________________________________________________
___________________________________________________ By _______________________________
Cost estimate ____________ actual ____________ Signature _______________ Date________________
Work organisation defect
Action _______________________________________________________________________________
__________________________________________________ By ________________________________
Cost estimate _____________ actual _____________Signature ______________ Date _______________
Outside agency
Action _______________________________________________________________________________
_________________________________________________ By _________________________________
Cost estimate ___________ actual _____________Signature _____________ Date __________________
Other
Action _______________________________________________________________________________
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_______________________________________________ By __________________________________
Cost estimate __________ actual ____________ Signature _____________ Date ___________________
Name ________________________________________________________________________________
Job title _______________________________________ department _____________________________
Date of accident ____________________ Place of accident _____________________________________
ACCIDENT REPORT
Accident occurred
In normal working hours/overtime Outside working hours
On employers premises On other private/public property
Obeying instructions Disobeying instruction
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Classification of cause
Burn Electrical shock Fall Health hazard
Struck Trapped Mechanical Other
Nature of personal injury
State Statutory Sick pay/Invalidity Benefit: claimed ________ granted ________ terminated _______
Absence
Estimated length of absence from work _____________________________________________________
Actual absence from work ________________________________________________________________
If employee returned to different employment specify nature and reason ___________________________
______________________________________________________________________________________
Medical attention given
By works medical centre By doctor At hospital
Address and telephone of hospital and/or doctor
_____________________________ Hospital Doctor ______________________________________
_____________________________________ ____________________________________________
_____________________________________ ____________________________________________
Telephone ___________________________ Telephone ___________________________________
Means of transport to hospital or doctor ___________________________________________________
Length of detention in hospital _____________________ X Ray
Hospital patient No. ______________________________ X Ray Dept. No. ___________________
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Notification to :
Safety Office Date ________________ Safety representative Date ______________
Union Officer Date ________________ Engineer Date ______________
Accident register Date ________________
Scene inspected _______________________________________________________________________
EMPLOYEES SUGGESTION
INSTRUCTIONS Write your suggestions clearly indicating exactly what is to be done. If you
need more space or if it is necessary to draw a sketch use the back of this form or attach securely a
sheet of plain paper.
MY SUGGESTION IS : _________________________________________________________________
MY SUGGESTION WILL ACCOMPLISH THE FOLLOWING : _____________________________
PLEASE PRINT
Name : _______________________________________________________________________________
Address : _____________________________________________________________________________
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Department : __________________________________________________________________________
Tel/ext. No: ___________________________________________________________________________
All suggestions become the property of the company to do with as it sees fit.
Employees signature __________________________________________________________________
Date : ______________________
DISCIPLINARY WARNING RECORD
______________________________________________________________________________________
Employees Name _____________________ Clock or __________ Dept. ________________________
Payroll No.
WARNING
Date of voilation _______________ Time of violation ____________ Place violation occurred _______
NATURE OF VIOLATION Substandard work Conduct Tardiness
Carelessness Disobedience Uncooperative
COMPANY REMARKS
Has employee been warned previously YES NO
______________________________________________________________________________________
Form of warning WHEN WARNED and BY WHOM
__________________________________________________________________
1st warning 2nd warning 3rd warning
______________________________________________________________________________________
Oral______________________________________________________________________________________
Written
______________________________________________________________________________________
EMPLOYEES REMARKS RE: VIOLATION
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The absence of any statement on the part of the EMPLOYEE indicates his/her agreement with the
report as stated.
I have entered my version of the matter above.
Employees Signature ____________________________________ Date __________________________
ACTION TO BE GIVEN
Approved by Name ____________________ Title ____________________ Date __________________
I have read this warning
and understand it.
Employees Signature __________________________________________ Date ____________________
Signature of person
Who prepared warning ___________________ Title _______________ Date _____________________
Supervisors signature ________________________________________ Date _____________________
Employee Personnel Department Foreman or Plant Manager
Supervisor