1
Florida Department of Education
Survey of Dropouts/Intent to Terminate Enrollment
School Name ______________________________________________ School District _________________
Student Name ______________________________________________ Student DOB ________________
Grade Level ______________________________________________ Date ________________________
Directions: Please circle 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?
A. Classes were not interesting/bored K. Student-teacher conflict
B. Missed too many days and could not catch up L. Employment/have to work full-time
C. Did not like school
M. Friends dropped out
D. Failing classes/couldn’t keep up with school work N. Failed to pass FCAT
E. Illness O. Intimidated/Threatened/Bullied
G. Getting married Q. Homeless
H. Felt like I did not belong R. Family Problems
I. Suspended from school often
J. Expelled from school
Other:____________________________________________________________________________________
_________________________________________________________________________________________
2. Which of the following best describes your
secondary
reason for terminating school enrollment?
A. Classes were not interesting/bored K. Student-teacher conflict
B. Missed too many days and could not catch up L. Employment/have to work full-time
C. Did not like school
M. Friends dropped out
D. Failing classes/couldn’t keep up with school work N. Failed to pass FCAT
E. Illness O. Intimidated/Threatened/Bullied
F. Became a parent P. Migrant
G. Getting married Q. Homeless
H. Felt like I did not belong R. Family Problems
J. Expelled from school
Other:____________________________________________________________________________________
_________________________________________________________________________________________
2
3. What would have improved your chances of staying in school? (Circle all that apply.)
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:____________________________________________________________________________________
_________________________________________________________________________________________
4. What actions did your school personnel take to keep you enrolled in school? _________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Please check and sign below to certify that each of the following statements was addressed by school
personnel.
I am at least 16 years of age and it is my intent to terminate my school enrollment. I received counseling from a
guidance counselor or other school personnel which addressed the following:
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.
For Bright Futures eligibility, GED students must complete credit requirements before taking GED exam.
Student Signature: ____________________________________________ Date: ________________________
Parent/Guardian Signature: _____________________________________ Date: ________________________
(if student is under 18 years of age)
School Personnel Signature: ______________________________________ Date: ________________________
Optional:
1. What is the highest level of education completed by your maternal parent/guardian? (circle one)
Elementary Middle School High School College Graduate School Unknown
2. What is the highest level of education completed by your paternal parent/guardian? (circle one)
Elementary Middle School High School College Graduate School Unknown