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 candidate’s 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
candidate’s background are covered.

As the interviewer, you not only know the candidate’s record, but you have
some understanding of the candidate’s 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 candidate’s sincerity, confidence and tact.

Name of applicant ______________________________________ Date ____________

Position applied for _________________________________ Reference _____________

 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 noted
during 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 ?
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 ?

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 unemploy
ed, 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 ?

 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.
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 candidate’s 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 ?

_____________________________________________________________
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 ?

 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 ten
years ?

___________________________________________________________

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 ?
___________________________________________________________
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 very
aloof warm and
outgoing
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 instantly
Explanation

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 faultless
Areas 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 match
Expected

9. SKILL

None appropriate Some skill in job Reasonable Well skilled in Excellent skills
Area amount, average area ideal for job
for job
10. EXPERIENCE

No relation Some experience Average, Well skilled in Excellent skills

Between in relevant area background job area ideal for job
Background and covers job
Job 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 required
Standard

The applicant should be offered the job

Considered for further interview

Placed on reserve list

Rejected

Signature of interviewer _________________________________________________________________

Reasons and comments ___________________________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________
 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 interviewer’s opinions as to the candidate’s suitability for placement within
This the organisation.
Employment
Interview
Summary

Overall The interviewer’s 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: Interviewer’s 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

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 interviewer’s opinions as to the candidate’s suitability for placement within
this the organisation.
Employment
Interview
Summary

Overall The interviewer’s 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 : Interviewer’s 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 requirements

Probably 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.

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. The
evaluator 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 Attention to requisite detail

To completeness, avoidance of superficiality
Reason (s) for your rating :

SECTION ‘B’
Poor 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

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
goals.
Reason(s) for your rating :
 Creativeness improvement of
Methods, procedures, etc. by
new ideas.
Reason (s) for your rating :

Education Job relatedness of

Candidate’s 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 and
Options.
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 _______________________________________________________________________

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)
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 ____________________________

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?
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 of
work?

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

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
____________________________________________________________________________________

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 Supervisor
Pay Salary
______________________________________________________________________________________
Describe the work you did
__________________________

__________________________
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 : _________________________________________

 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 employee’s performance ? ________________________________

Warning (s) Details _______________________________________________________

Extra training _______________________________________________________

Diminished duties _______________________________________________________

Extra supervision _______________________________________________________

Other _______________________________________________________
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 ____________________________

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?

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 ? ___________________________________

______________________________________________________________________________________

_______________________________ 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 ?

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

Interviewer’s assessment of the real reasons for leaving :

_______________________________________________________________________
_
______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

_______________________________________________________________________
_
______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Interviewer’s recommendation for future action (if required)

_______________________________________________________________________
_
______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

_______________________________________________________________________
_
______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Interviewer’s signature : ____________________________ Date : ______________________________

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
______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

New memberships in technical or professional societies _________________________________________

______________________________________________________________________________________
New professional offices or honours ________________________________________________________

_____________________________________________________________________________________

Any other changes you would like us to note _________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Employee’s signature : _____________________ Reviewed by : _________________________________

EMPLOYEE CHANGE OF JOB REPORT

Prepare in triplicate : 1 Personnel 2 Payroll 3 Employee’s Department

Please enter the following change(s) as of ____________________________________________________

Name ________________________________ Clock or payroll No : _______________________________

NIC No : _______________________________________

FROM
______________________________________________________________________________________
Job Dept. Shift Rate
______________________________________________________________________________________

______________________________________________________________________________________

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.

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 ________________________________________

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 _____________________________________________________________

Employee’s claim

Damages : action__________________ By _____________ Cost ___________ Result ______________

Nat. Ins. Action __________________ By _____________ Cost ___________Result _______________

Other : action __________________ By _____________Cost ____________Result _______________

Insurance claim

Action ______________________________________ By _____________________________________

Cost _______________ Result ___________________________________________________________

Inquiry

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 _________________

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 _______________________________________________________________________________

_______________________________________________ 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 employer’s premises On other private/public property

Obeying instructions Disobeying instruction

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 work’s 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. ___________________

Notification to :

Safety Office Date ________________ Safety representative Date ______________

Union Officer Date ________________ Engineer Date ______________

Accident register Date ________________

Scene inspected _______________________________________________________________________

EMPLOYEE’S 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 : _____________________________________________________________________________

Department : __________________________________________________________________________

Tel/ext. No: ___________________________________________________________________________

All suggestions become the property of the company to do with as it sees fit.

Employee’s 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
______________________________________________________________________________________

EMPLOYEE’S REMARKS RE: VIOLATION

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.

Employee’s Signature ____________________________________ Date __________________________

ACTION TO BE GIVEN

Approved by Name ____________________ Title ____________________ Date __________________

I have read this ‘warning’

and understand it.

Employee’s Signature __________________________________________ Date ____________________

Signature of person
Who prepared warning ___________________ Title _______________ Date _____________________

Supervisor’s signature ________________________________________ Date _____________________

Employee Personnel Department Foreman or Plant Manager

Supervisor

The Author Prof.Lakshman Madurasinghe, MA.,MS(Psy).PhD

Chartered Fellow CIPD(Lond) is a Behavioural Scientist with
International HR Consultancy experience

Website: http://lmadurasinghe.googlepages.com