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 have
some 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 _____________

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 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 ?

_____________________________________________________________

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

2.

Somewhat
Careless about
Personal
Appearance

Satisfactory
personal
appearance

Neat and tidy,

better than
average
appearance

Reserved

Approachable
fairly friendly

Warm, friendly
sociable

unusually well
groomed and
very neat.

FRIENDLINESS
Appears very
distant and
aloof

Extremely
friendly very
warm and
outgoing

3. POISE
Ill at ease, jumpy
And very nervous

Somewhat tense
easily irritated

Reasonably at
ease

Self assured

Extremely well
composed

Average and
Satisfactory

Very good, above

average

Hesitant, lower
than average
Fluency and

Average fluency
and expression

Talks well and

does not waste
words

Excellent
expression
extremely fluent

Rather slow
requires more
Than average
Explanation

Grasps ideas with

average speed

Quick to
understand
perceives well

Exceptionally alert
understands new
ideas instantly

Limited
knowledge
covering some
Areas

Average
knowledge not
covering all
areas fully

Well informed
knowledge
covers all areas

Excellent
knowledge with
faultless
coverage

Some relevance
To job

Satisfactory, as
good as might be
Expected

Very suitable
for job

Ideal for job

perfect match

Some skill in job

Area

Reasonable
amount, average
for job

Well skilled in
area

Excellent skills
ideal for job

4. PERSONALITY
Unsatisfactory

Doubtful

Outstanding
excellent all
round.

5. CONVERSATIONAL ABILITY

Talks very little

Poor expression

6. ALERTNESS
Very slow to grasp
Ideas

7. KNOWLEDGE OF WORK FIELD

Poor, no
Appropriate
Knowledge at all
8.

QUALIFICATIONS
Not relevant to job

9.

SKILL
None appropriate

10. EXPERIENCE
No relation
Between
Background and
Job requirement

Some experience
in relevant area

Average,
background
covers job
area

Well skilled in
job area

Excellent skills
ideal for job

11. DRIVE AND

INITIATIVE
Poorly defined
Goals, acts
without purpose

Makes little effort

to achieve goals

Average effort
some initiative

High desire to
achieve, strives
hard.

Sets high goals

always takes
Initiative

Below standard
But just
Acceptable

Average

Above average
higher than
required
Standard

Outstanding

12. OVERALL
Unsatisfactory

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
Information

Name ___________________________________________________________________
Address _________________________________ Telephone _______________________
Position applied for ________________________________________________________
Date of Interview ___________________ Place of interview _______________________

Purpose of
This
Employment
Interview
Summary

To record the interviewers opinions as to the candidates suitability for placement within
the organisation.

Overall
Evaluation
Of the
candidate

The interviewers overall evaluation of the candidate should be based on the detailed
evaluation contained herein, and should be summarised below after the completion of the
interview.
Recommended

Not recommended for

______________________________________________________ because
Position
Prepared by:

Interviewers name _____________________ Title _____________________________

Signature __________________________________________ Date ________________

Instructions for
Sections A,B,
And C

Sections A, B and C require rating the candidate on characteristics usually pertinent

to job performance of executive, administrative and professional personnel. Omit any
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
Information

Name ____________________________________________________________________
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
Interview
Summary
Overall
Evaluation
Of the
candidate

The interviewers overall evaluation of the candidate should be based on the detailed
evaluations contained herein and should be summarised below after the completion
of the interview.
Recommended

Not recommended for

_____________________________________________________ because
Prepared by :

Interviewers name ________________________ title ___________________________

Signature __________________________________ Date ________________________

Instructions for
Sections A,B,
and C

Sections A, B and C require rating the candidate on characteristics usually pertinent to

job performance of executive, administrative and professional personnel. Omit any
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
Supervisory
Performance
Organisation Division of total operation
into efficient independent components
Reason (s) for your rating :
Personnel selection identification of job

Fair Average

Good

Excellent

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)
Cooperation Working effectively
with others to achieve common

Poor

Fair

Average

Good

Excellent

goals.
Reason(s) for your rating :

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

____________________________________________________________________________________
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
Unsatisfactory

Substandard
but making
Progress

Average

Definitely
above
average

Outstanding

What steps have been taken to improve employees 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
Interviewers assessment of the real reasons for leaving :
_______________________________________________________________________
_
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

_______________________________________________________________________
_
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Interviewers recommendation for future action (if required)

_______________________________________________________________________
_
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

_______________________________________________________________________
_
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Interviewers 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
Including yourself _______________

Number of
Children ____________

Their
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 _________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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
______________________________________________________________________________________

______________________________________________________________________________________

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 _____________________________________________________________
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

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 employers 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 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 _____________________
Hospital patient No. ______________________________

X Ray
X Ray Dept. No. ___________________

Notification to :
Safety Office

Date ________________

Safety representative Date ______________

Union Officer

Date ________________

Engineer

Accident register

Date ________________

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 : _____________________________________________________________________________

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
Carelessness

Substandard work

Conduct

Disobedience

Uncooperative

Tardiness

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

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
Supervisor

Plant Manager