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    Kentucky Department of Education: in Accordance With KRS 159.140 and 702 KAR 7:125

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    Rashad Ali
    This document is a student dropout questionnaire from the Kentucky Department of Education. It collects information about students who are withdrawing from school, including their name, grade level, age, primary reason for withdrawing, attendance history, academic performance, and plans after leaving school. Guidance counselors are required to follow up with students who dropped out after 3 months and before the next school year to obtain updates on their employment and education status.

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    Kentucky Department of Education: in Accordance With KRS 159.140 and 702 KAR 7:125

    Uploaded by

    Rashad Ali
    425 views2 pages
    This document is a student dropout questionnaire from the Kentucky Department of Education. It collects information about students who are withdrawing from school, including their name, grade level, age, primary reason for withdrawing, attendance history, academic performance, and plans after leaving school. Guidance counselors are required to follow up with students who dropped out after 3 months and before the next school year to obtain updates on their employment and education status.

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    Questions

    Original Title

    Dropout Questionnaire

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    This document is a student dropout questionnaire from the Kentucky Department of Education. It collects information about students who are withdrawing from school, including their name, grade level, age, primary reason for withdrawing, attendance history, academic performance, and plans after leaving school. Guidance counselors are required to follow up with students who dropped out after 3 months and before the next school year to obtain updates on their employment and education status.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    425 views2 pages

    Kentucky Department of Education: in Accordance With KRS 159.140 and 702 KAR 7:125

    Uploaded by

    Rashad Ali
    This document is a student dropout questionnaire from the Kentucky Department of Education. It collects information about students who are withdrawing from school, including their name, grade level, age, primary reason for withdrawing, attendance history, academic performance, and plans after leaving school. Guidance counselors are required to follow up with students who dropped out after 3 months and before the next school year to obtain updates on their employment and education status.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    DSS July 2010

    Kentucky Department of Education

    Student Dropout Questionnaire


    In accordance with KRS 159.140 and 702 KAR 7:125 District:
    School:

    Student Name: Withdrawal date: ___/___/___


    Grade Level:
    Age: 16 17 18 or over

    What is the primary reason the student is withdrawing from school? (check one)

    Course selection Employment Expulsion


    Student/teacher conflict Marriage Family Problems
    Failing classes Pregnancy
    Boredom Illness

    Was the student in an alternative setting prior to withdrawal from school? Yes No
    If no, was an alternative setting available? Yes No

    Had the student received individual counseling prior to this meeting? Yes No

    Was the student involved in school sponsored extracurricular activities? Yes No

    Does the student have an educational disability requiring an IEP? Yes No

    Has the student received any remediation services in the past three (3) years? Yes No

    What is the average number of days the student was absent over the past three (3) years? _____

    Has the student ever been suspended? Yes No If yes, how many times? _____

    Has the student ever been expelled? Yes No If yes, how many times? _____

    Is the student eligible for the free/reduced lunch program? Yes No

    Does the student plan to earn a GED? Yes No

    Optional: What is the highest level of education completed by either parent/guardian? (check one)
    Elementary Middle School High School College Graduate School

    Student Signature: Date:

    Parent/Guardian Signature: Date:


    (if student under 18 years of age)

    Guidance Counselor Signature: Date:

    July 2010 Page 1 of 2


    DSS July 2010

    KRS 159.010(4) COMPLIANCE:

    Three (3) month follow-up:

    Method of contact:

    Letter (Level I) Phone call (Level II) Home visit (Level III)

    Contact Successful Contact Unsuccessful

    Employment status:

    Employed full–time Employed part-time Unemployed Unknown

    Education status:

    Working on GED
    Earned GED
    Enrolled in another school
    Unknown

    Did the student return to school following this contact? Yes No

    Final contact (prior to start of next school year):

    Not applicable: Student returned to school ___/___/___

    Method of contact:

    Letter (Level I) Phone call (Level II) Home visit (Level III)

    Employment status:

    Employed full–time Employed part-time Unemployed Unknown

    Education status:

    Working on GED
    Earned GED
    Enrolled in another school
    Unknown

    Reading level from the three (3) most recent norm referenced assessments:

    Student Score: __________ __________ __________


    Student Grade: __________ __________ __________
    Student Age: __________ __________ __________

    July 2010 Page 2 of 2

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