STUDENT'S NAME (LAST, FIRST):
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THIS PROGRAM:
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STUDENT'S ADDRESS:
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STUDENT'S PROGRAM (IF DIFFERENT):
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INSTRUCTOR-ADVISOR'S NAME:
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STUDENT'S PHONE NUMBER:
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STUDENT'S E-MAIL ADDRESS:
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TERM OR DATE OF ENTRY:
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GENDER:
  Female Male |
AGE: |
CURRENT EMPLOYER (IF EMPLOYED):
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JOB TITLE (IF EMPLOYED):
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HIGH SCHOOL ATTENDED:
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DEGREE GOAL:
AA, AS, or AAS Certif None |
STUDENT'S GOAL OR OBJECTIVE IN THE PROGRAM OR COURSE: (Select closest choice; do not list another)
Obtain job for which the program will train
Satisfy job requirement, or obtain promotion or reassignment
Pursue general job-related interest (no specific job-related goal)
Pursue interest only (job in the field not sought)
Satisfy a requirement of another HCC program
Satisfy a requirement of DVR or other benefit program
Prepare for transfer to an institution for more advanced training
Maintain college enrollment until an opening occurs in another program
Undecided |
STATUS AT END:
Disappeared
Withdrew:
| Met original goal |
Moved |
| Lost interest |
Family or personal problem/obligation |
| Needed the tuition refund |
Job schedule changed |
| Obtained a job that conflicts with class times |
| Other training opportunity that was being awaited occured |
| Course or program turned out to be more difficult than expected at enrollment |
| Course or program turned out to be different from what expected at enrollment |
| Unresolvable conflict with an instructor in the program |
| Unresolvable conflict with another student in the program |
| Other circumstance |
Finished (received certificate or degree if major; completed course or courses if non-major)
Failed course(s) (non-majors taking one or a few courses in the program) |
FOLLOW-UP RECORD (if applicable):
________ Date initial survey form sent
________ Date second survey form sent
________ Date of other follow-up |
END DATE:
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