DROPOUT SUPPLEMENT FORM 2016-2017

This form is to be completed and attached to the Exit Survey (student/parent) or the One Year Follow Up Survey
ONLY if the student dropped out of school during the school year for which the survey is completed. If surveys
are mailed, please complete and attach this form ONLY if the student dropped out of school.

First Name MI Last Name

Birth date: / / WVEIS #:

High school: Eligibility:
County: Gender:  Female  Male
Race:

Please mark the reason for dropping out of school (check all that apply)

 Academic difficulty  Marriage

 Behavior difficulty  Pregnancy

 Dislike of the school experience

 Economic Reasons  Needed at home

 Employment  Parental Influence

 Exceeded allowable absences  Physical illness or disability

 Family care responsibilities  Poor student/staff relationship

 Lack of appropriate curriculum  Poor relationship with fellow students

 Lack of interest or motivation  Transportation difficulties

 Expelled (with no option to return for the remainder of the school or 12 months)

 Other:

Additional comments:

Note: This form is a supplement to: WVDE-ISS-056 Exit Survey