Early Intervention Exit Interview

Universal Form

I have worked in Early Intervention for:

____0-1 year ____1-2 years ____2-3 years _____ 3-4 years _____ 4-5 years

If more than five years, please indicate how many:______

I successfully completed the process to be a Certified Early Intervention Specialist (CEIS) ___yes ___no

This was my first job in my field:

Yes_____ No_____

I was employed

____ full time ____ part time

___ Salaried ____ Hourly____ Consultant ______

Discipline:

___a ___b ___c ___d___ Developmental Specialist __Speech Therapist __Physical Therapist __Social Worker __Psychologist __ Occupational Therapist __Nurse

_____________Other

Please indicate the reasons that you have decided to leave your EI program. Please indicate all that apply with 1 being the most important and 5 the least important (Note: you may use a number more than once.)

__ Better Salary

__ Improved Benefits (circle all that apply): health insurance, vacation time, job flexibility, tuition reimbursement, sick time, mileage

503B, child care, disability insurance, flexible spending account

__ Productivity requirements/insufficient time to complete the job

__ Travel/commute

__ Seeking job advancement/new responsibilities

__ Early Intervention did not match my interests

__ Did not want to participate in the certification process

__ Need for more clinical supervision in my field

__ Relationship with supervisor

__ Moved from area

__ Family responsibilities – baby, spouse lost job

__ Lack of support from the Team

__ Lack of appreciation from the Program

__ Could no longer physically do the work

__ Safety issues while in the field

__ Retirement

__ Other( Please explain):

Would you have liked to continue working at your EI program? Yes__ No__

Please indicate changes that would have influenced you to stay at your job:

__ More competitive salary/Incentives

__ Better benefits (Please circle which ones apply):

Health insurance, vacation time, job flexibility, tuition reimbursement,

503B, child care disability insurance, flexible spending account, mileage

__ More time to complete the job

__ Improved relationship with supervisor

__ Decreased productivity

__ Professional advancement

__ More clinical supervision in my field

__ More center based work

__ More alternatives in the certification process

__ Loan forgiveness

__ Opportunity for Mentorship

__ Opportunity to do something different in EI

__ Other (Please explain)

Please rate your overall satisfaction with the job on a scale of 1-5 with 1 being most satisfied and 5 least satisfied:

___1 ___2 ___3 ___4 ___5

The job that I have accepted is in:

___ school system

___other EI program

___outpatient clinic

___VNA

___hospital

___private practice

___have not accepted another position

___other:____________________________________________________________

Please share any other additional information that may help us understand how we can promote staff retention in early intervention. (Include the difference in salary and benefits if you are comfortable.)_______________________________

____________________________________________________________________

____________________________________________________________________

_____________________________________________________________________

Thank you for participating in this survey

______________________________ _______________________

Name & Program (Optional) Date:

Developed 2005 by MEIC