Instructions
Answer questions as they relate to the student. For most answers, check the boxes most applicable or fill in the blanks.
First Name*
Last Name*
School*
Access Center*
1.
Month Survey Conducted?
2.
Student Name
3.
Student ID No.
4.
Student Social Security No.
5.
School
6.
School Code
7.
Grade/Section
8.
Date of Birth
9.
Ethnicity
10.
Gender
11.
Student Address
12.
City
13.
State
14.
Zip Code
15.
Phone No.
16.
Name of relative outside your home
17.
Relationship
18.
Relative's Address
19.
City, State, Zip Code
20.
Additional Contact Address
21.
22.
Did Student Dropout ?
Yes
No (Skip to Q. 31)
23.
Medical
24.
Non Attendance
25.
Disciplinary
26.
Age
27.
Hardship
28.
Academic
29.
Marriage
30.
Other
31.
Transferred to another School?
No
32.
Presently enrolled at school name:
33.
Received Regular Diploma at school:
34.
Received GED at school:
35.
Presently employed at Company:
36.
Assisted in returning to school
37.
Provided referral services for employment
38.
Assisted with Alternative Employment (i.e., Job Corp, Community based organization)
39.
Comments
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