Exit Interview Student Survey

School Name ______School District ______

Student Name ______Student DOB ______

Grade Level ______Date ______

Directions: Please check the response that best describes your experience or provide a description of your experience in the space provided.

  1. Which of the following best describes your primary reason for terminating school enrollment?

___Classes were not interesting/bored ___Student-teacher conflict

___Missed too many days and could not catch up ___Employment/have to work full-time

___Did not like school ___Friends dropped out

___Failing classes/couldn’t keep up with school work ___Failed to pass end of semester exams

___Illness ___Intimidated/Threatened/Bullied

___Became a parent ___Migrant

___Getting married ___Homeless

___Felt like I did not belong ___Family Problems

___Suspended from school often Other: ______

___Expelled from school

  1. Which of the following best describes your secondary reason for terminating school enrollment?

___Classes were not interesting/bored ___Student-teacher conflict

___Missed too many days and could not catch up ___Employment/have to work full-time

___Did not like school ___Friends dropped out

___Failing classes/couldn’t keep up with school work ___Failed to pass end of semester exams

___Illness ___Intimidated/Threatened/Bullied

___Became a parent ___Migrant

___Getting married ___Homeless

___Felt like I did not belong ___Family Problems

___Suspended from school often Other: ______

___Expelled from school

  1. What would have improved your chances of staying in school? (check all that apply.)

___Opportunities for real-world learning (internships, service learning)

___Better teachers

___Smaller classes

___More individualized instruction

___Better communication with your teachers

___Better communication with your parents

___Increased parental involvement

___Less freedom and more supervision from parents

___Less freedom and more supervision from school officials

___Additional tutoring or interventions

Other : ______

  1. What actions did your school personnel take to keep you enrolled in school? (Check all that apply.)

I am at least 16 years of age and it is my

___Provide student counseling

___Scheduled a conference with parent(s), guardian(s), student and school staff

___Discussed and offered options for tutoring

___Discussed the consequences for dropping out

___Discussed and offered options for continuing education in a different environment (eg.,

___Adult education, home school, virtual school, hospital homebound)

___Discussed and offered alternative options for graduation (eg., diploma options or GED Option)

___Conducted home visits

___Referred student to agencies/programs to address problems interfering with school success (eg. substance abuse counseling, psychological counseling, family counseling)

___Discussed and offered participation in a credit recovery course/program

___Discussed and offered access to Dropout Prevention Program (s) (eg. alternative education, disciplinary, teenage parent)

___Tracked student progress (by teacher, counselor, social worker, graduation coach,etc.)

___Changed or revised course schedule

___Implemented intervention contracts (eg., attendance or behavior)

___Student reported that school staff took no action

Other: ______

___Student did not drop out of school after meeting with school staff.

___Student did not provide information about actions taken.

Please check and sign below to certify that each of the following statements was addressed by school personnel.

I am at least 16 (17 for freshmen Fall 2011 and beyond) years of age and it is my intent to terminate my school enrollment. I received counseling from a school counselor and/or school administrator which addressed the following:

I am at least 16 years of age and it is my

Terminating school enrollment prior to graduation will likely reduce my potential earnings and negatively affect my career options.

Termination of school enrollment will result in the revocation/denial of my driving privileges until age 18.

My reasons for leaving school prior to graduation.

Possible actions that could keep me from leaving school prior to graduation.

Options for continuing my education in a different environment, (e.g., Adult Education or GED testing.

Community college).

Without a high school diploma, I may not be eligible for military entrance.

eelor, social worker, graduation c

Education, home school, virtual school, hospital etc.

homebound) L. Changed or revised course schedule

F. Discussed and offered alt

Student Signature: ______Date: ______

Parent/Guardian Signature: ______Date: ______

(if student is under 18 years of age)

School Personnel Signature: ______Date: ______

Additional Information Requested:

1. What is the highest level of education completed by your maternal parent/guardian? (check one)

___Elementary /Middle School

___High School

___College Graduate

___Beyond 4 year college graduate

___School Unknown

2. What is the highest level of education completed by your paternal parent/guardian? (check one)

___Elementary/Middle School
___High School
___College Graduate
___Beyond 4 year college graduate
___School Unknown

I am leaving school to pursue the following education/career plan:

Goal / Action Plan / Time Frame