STUDENT EXIT FORM

SFY 2012 (2011-2012)

Name:______

LastFirstM.I. Maiden or other former name

Social Security #: ______- _____-______GED Security #: _____-____-_____ Site: ______Instructor:______

Reasons for attending / GOALS / Exit goal achieved /

Reasons for leaving

Primary / Secondary / (mark all that apply) / Why did the student leave the program?
 /  / Improved basic skills /  / (mark all that apply)
 /  / Improved English language skills (ESOL) /  /  / Met primary goal
 /  / Obtained a job /  /  / Met secondary goal
 /  / Retained or improved a job /  /  / Met academic goal (if other than
 /  / Earned GED or secondary school diploma /  /

primary or secondary goal)

 /  / Entered postsecondary education or training /  /  / Class closed
 / Decreased public assistance received /  /  / Family problems
 / Obtained citizenship skills /  /  / Illness/incapacity
 / Passed citizenship test /  /  / Instruction not helpful
 / Registered to vote or voted for the first time /  /  / Lack of child care
Increased involvement in community activities /  /  / Lack of transportation
Obtained Stackable Pilot certificate
Basic: certificate #______date issued: ______
Advanced: certificate #______date issued: ______
Oral Comm.: certificate #______date issued: ______/ 

 /  / Moved
 / Lack of interest
 / Time and/or location of services not
convenient
Obtained National Career Readiness Credential ______/  /  / Unknown/cannot locate or contact
 / Other (specify:______) /  /  / Other (specify: ______)
Family Literacy goals (for students in Family Literacy programs only)
 / Increased involvement in children’s education /  / Total hours attended
 / Increased involvement in children’s literacy-related activities / 
Placement level / Exit level / Exit level status
ABE
Beg. Lit.
Beginning
LowInt
HighInt
Low ASE
High ASE / ESOL
Beg.Lit.
Low Beg.
High Beg.
Low Int.
High Int.
Advanced / ABE
Beg.Lit.
Beginning
LowInt
HighInt
Low ASE
High ASE / ESOL
Beg.Lit.
Low Beg.
High Beg.
Low Int.
High Int.
Advanced / Exit level status / Assessment used to determine level completion
Completed a level / List assessment used______
And left / (Assessment must be entered into ABLELink)
And advanced to a higher level
 Separated before completing a level
 Progressing at the same level

Student Exit Form

OPTIONAL Goals

Please mark all of the non-academic goals achieved.

Educational Goals / Outcome achieved (mark all that apply) / Community Goals / Outcome achieved (mark all that apply)
Wrote letter /  / Obtained driver’s license/state ID / 
Read first book /  / Got a library card / 
Completed a workbook /  / Used the library / 
Used a computer to create a document /  / Read and understood product labels/used coupons / 
Used a computer to search the internet /  / Volunteered in the community / 
Used a computer to create and send e-mail /  / Read newspaper/newsletter / 
Improved money skills /  / Used public transportation / 
Used correct measurement unit to perform a function / 
Gave/understood oral directions / 
Occupational Goals / Outcome achieved (mark all that apply) / Personal Goals / Outcome achieved (mark all that apply)
Passed job-related test /  / Opened bank account / 
Received award/recognition at work /  /
Improved banking and/or credit skills
/ 
Recognized survival signs /  / Bought house/rented apartment / 
Learned safety procedures /  / Paid bills by self / 
Filled out job application /  / Used recipe to create a meal / 
Completed resume /  / Filled out forms / 
Completed time card/time sheets /  / Read menu / 
Went on job interview /  / Improved telephone skills / 
Completed trial employment period /  / Relayed personal information / 
Read personal mail / 
Read the Bible or other book for pleasure / 
Created a budget / 
Met own needs using a community resource/agency / 
Read and understood health related materials / 

April 2011 1/2Student Exit Form FY2012