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    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

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