Participant Termination And Exit Interview Form, Verification Of Employment Form - Alaska Commission On Aging
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1
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3Alaska Commission on Aging
Senior Community Service Employment Program
PO Box 110209
Juneau AK 99811-0209
PARTICIPANT TERMINATION AND EXIT INTERVIEW
GRANTEE: ____________________________
GRANT #______________
This form must be completed immediately upon termination and sent to ACoA whether
or not the participant is available to sign.
NAME: __________________ SSN# ____________________ Position # _________
Termination code & Termination Date ________________ (Circle one)
A- Employed Private Sector
B-Employed, Nonprofit
C-Employed, Public Sector
D- Moved form area
E-Refused to continue
F-Other (please explain)
G-Terminated (explanation required)
_____________________________________________________________________
_____________________________________________________________________
In what ways has the Senior Community Service Employment Program been helpful to
you?
_____________________________________________________________________
_____________________________________________________________________
How useful was the training you received in your Senior Community Service
Employment Program position?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Other Comments
_____________________________________________________________________
_____________________________________________________________________
_______________________________
_____________________
Participant Signature
Date
_______________________________
_____________________
Preparer’s Signature
Date
COMPLETE THIS SECTION ONLY IF THE PARTICIPANT IS EMPLOYED AFTER LEAVING
THE SCSEP POSITION.
New Employer ____________________________
Telephone ____________
Job Title _________________________________
Wage/HR _____________
Start Date ____________ Supervisor __________________________________
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Anticipated Duration of Employment ___________ Full Time
Part Time
Temp
UNSUBSIDIZED EMPLOYMENT MUST BE VERIFIED AFTER 30 DAYS. PLEASE SEE
VERIFICATION OF EMPLOYMENT FORM ON THE REVERSE SIDE.
F:\Website\employ\ExitInterview.doc
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