1
     
    Florida Department of Education
    Exit Interview
     
    To be completed by school guidance counselor or other school personnel:
     
    School Name ______________________________________________ School District _________________
     
    Student Name ______________________________________________ Withdrawal date: __/__/__
     
    Grade Level ______________________________________________ Student ID# __________________
     
    Student DOB ______________________________________________ School Transcript (
    Please Attach
    )
     
    What is the
    primary
    reason the student is terminating school enrollment? (check one)
     
    ___ Classes not interesting ___ Marriage ___ Employment
    ___ Student/teacher conflict ___ Parenting ___ Suspended too often
    ___ Friends dropped out ___ Illness ___ Homeless
    ___ Failing classes ___ Migrant ___ Truancy/Absenteeism
    ___ Did not like school ___ Expelled ___ Failed to pass FCAT
    ___ Family Problems ___ Intimidated/Threatened/Bullied
     
      
      
      
      
      
      
      
      
    Other:____________________________________________________________________________________
    _________________________________________________________________________________________
      
      
      
      
      
    Was the student in an alternative program prior to withdrawal from school? Yes No
    If no, was an alternative program available? Yes No
    If yes, describe the alternative program? ___________________________________________________
     
    Had the student received individual counseling prior to this meeting? Yes No
    If no, was counseling made available to the student? Yes No
     
    Has a child study team been convened on the student’s behalf? Yes No
    If yes, please list the interventions taken by the child study team. _______________________________
    __________________________________________________________________________________________
    __________________________________________________________________________________________
    __________________________________________________________________________________________
     
    Was the student involved in school sponsored extracurricular activities? Yes No
     
    Does the student have an IEP or Section 504 Accommodation Plan? Yes No
     
    Has the student received any remediation services in the past two (2) years? Yes No
    If yes, please describe the remediation services? _____________________________________________
    __________________________________________________________________________________________
     
    What is the average number of days the student was absent over the past two (2) years?
    Year 1 ________ Year 2 ________
     
     
     

     
    2
     
    How many unexcused absences or tardies has the student accumulated over the past two years?
    Unexcused Absences: Year 1 _______ Year 2 ________
    Unexcused Tardies: Year 1 _______ Year 2 ________
     
    What interventions did the school attempt in response to unexcused absences or tardinesses of the student while
    enrolled?
    A.
     
    Communication between the school/teacher and the family/student
    B.
     
    Formal meeting with the parent
    C.
     
    Changes to the learning environment
    D.
     
    Student counseling
    E.
     
    Tutoring
    F.
     
    Attendance Contract
    G.
     
    Mentoring
    H.
     
    Referral to other agencies/services on behalf of family needs
    I.
     
    Truancy Petition
    J.
     
    Other (Please describe)
    __________________________________________________________________________________________
    __________________________________________________________________________________________
     
    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
    If yes, inform student, for Bright Futures eligibility, GED students must complete credit requirements before
    taking GED exam.
     
    Has the student been informed of options for continuing his/her education? Yes No
     
    Has the parent been notified of the student’s intent to terminate school enrollment? Yes No
    If yes, provide the date of parent notification. _______________________
     
      
      
      
      
      
    The student has identified the following as actions that could be taken to keep them in school.
     
    A. Opportunities for real-world learning (internships, service learning)
    B. Better teachers
    C. Smaller Classes
    D. More individualized instruction
    E. Better communication with your teachers
    F. Better communication with your parents
    G. Increased Parental Involvement
    H. Less Freedom and more supervision from parents
    I. Less Freedom and more supervision from school officials
     
    Other:____________________________________________________________________________________
    _________________________________________________________________________________________
     
    Has the student completed the student survey? Yes No
    If no, how many attempts did the school make to obtain a completed survey from the student? _______

     
    3
     
    The following section is included to encourage dropout retrieval efforts.
    Three (3) month follow-up: (
    Please check all that apply.)
     
    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 (private/vocational) ___Unknown
     
    Other (Please explain)________________________________________________________________________
     
    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)
     
    ___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 (private/vocational) ___Unknown
     
    Other (Please explain)________________________________________________________________________
     
    Did the student return to school following this contact? Yes No

    Back to top