I agree to participate in a post-school follow up, if contacted.

I understand that
any information I provide will be private and confidential and tell us how our
students do after they leave school. It can help us decide what we can do to
better prepare our students for work and college after high school. I understand
that my participation is strictly voluntary and my name will never be printed in a
report. Initial _____________
I do not wish to participate in any post school follow up. Initial _____________

2013-2014 School Year

North Carolina Student Exit Survey
Student Demographic Profile: (*) indicate required element
*1
*2
*3
4

School district Name: Iredell-Statesville Schools

School Name ________________________________________________________
Students Name *First_____________________ MI_____ *Last_______________
Students district
a. ID # (NCWISE) _________________________________
b. CECAS ID# _____________________________________
*5 Students Date of Birth _____/____/____ ) (mm/dd/yyyy)
*6 Did this student exit school during the 2013-2014 school year? (
( ) No
If yes, grade at time of exit: ( ) 9th
( ) 10th
( )11th
( ) OtherPlease Specify: _____________________
Write in Early College if applicable

) yes
) 12th

*7 Students PRIMARY special education disability (CHECK ONE

OPTION):
( ) Autism
( ) Behaviorally Emotionally Disturbed
( ) Deaf-Blind
( ) Hearing Impaired
( ) Intellectually Disabled
( ) Mild
( ) Moderate
( ) Severe/Profound
( ) Visually Impaired
( ) Orthopedically Impaired
( ) Multi-Handicapped
( ) Other Health Impaired
( ) Developmentally Delayed
( ) Specific Learning Disabled
( ) Speech-Language Impaired
( ) Traumatic Brain Injury
( ) Information not available
1

*8 Gender (CHECK ONE OPTION)

(
(

) Male
) Female

*9 Ethnicity as stated in school records (CHECK ONE OPTION)

(
(
(
(
(
(

)
)
)
)
)
)

American Indian or Alaska Native

Asian or Pacific Islander
Black (not Hispanic)
Hispanic
White (Not Hispanic)
Other (please specify) ________________________________

*10 Manner in which student exited school (CHECK ONE OPTION)

(
(
(
(
(

)
)
)
)
)

Graduated with regular high school diploma

Graduated with regular high school diploma AND an Associates Degree
Received a Graduation Certificate
Reached maximum age
Dropped out

If graduated with a regular high school diploma, which course of study?

(
(
(
(

) Career Course of Study

) College Tech Prep Course of Study
) College Prep Course of Study
) Occupational Course of Study

11. What post-school goals are included in this students IEP for the
period immediately following high school?
11 a. ( ) Attend a postsecondary school, training, or education
11 b. ( ) Secure employment
*12 Was this student identified as English Language Learner (ELL) or
Limited English Proficient (LEP) during the students last year in school?
( ) No
( ) Yes
*13 The follow up survey will be conducted by phone. Will this student
need an accommodation?
(
(

) No
) YesPlease specify_______________________________

Contact Information After Leaving High School

Please provide the most up to date contact information that you can.
Involve the student in choosing contacts and remind them to tell these
people that they may be contacted as part of North Carolinas Post school
Survey.
Parent/ Family Member
*First Name ________________________________
*Last Name _________________________________
*Primary Contact Number: area code _____ Phone number
_____________
Alternate Contact Number: area code _____ Phone number
______________
Email___________________________________________________
*Mailing Address:
_______________________________________________________________________________
_______________________________________________________________________________
Students Contact
( ) The student has the same phone and address as their parent. If
different from parents contact, indicate below
*Primary Contact Number: area code _____ Phone number
_____________
Alternate Contact Number: area code _____ Phone number
______________
Email___________________________________________________
*Mailing Address:
_______________________________________________________________________________
_______________________________________________________________________________
Alternate Contact: (Please indicate a person with whom the student
will have contact with upon graduation. This can be a Grandparent,
other close relative, Services Coordinator, neighbor etc.)
*First Name ________________________________
*Last Name _________________________________
*Primary Contact Number: area code _____ Phone number
_____________
Alternate Contact Number: area code _____ Phone number
______________
Email___________________________________________________
*Mailing Address:
_______________________________________________________________________________
_______________________________________________________________________________
Individual Completing Form: _____________________________________
3

Phone: Area code and phone number ________________________________

Email: ____________________________________________________________
Please forward completed surveys to:
Transition Coordinator, EC Department