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