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BuiltByNOF
 Post-School Survey

Respondent:

Date:

R

 Self

 Mother

 Father

 Legal Guardian

 Other

 
elationship to graduate:

 

Demographics

Graduate's Name:

Birthdate:

School graduated from and date of graduation:

Sex: Male  Female

 

 

Ethnic Origin

 Black Non-Hispanic

 White Non-Hispanic

 American Indian

 Hispanic

 Asian/Pacific Islander

 Other

 

1. Graduate's disability

(Check appropriate boxes)

 Autism

 Serious Emotional Impairment

 Deaf-blindness

 Specific Learning Disability

 Deafness

 Speech or language Impairment

 Hearing Impairment

 Traumatic Brain Injury

 Mental Retardation

 Visual Impairment, including blindness

 Multiple Disabilities

 

 Orthopedic Impairment

 

 Other Health Impairment

 

2. Services received while in school

(Check appropriate boxes)

 Full Inclusion

 Physical Therapy

 Resource Room

 Occupational Therapy

 Emotionally Disturbed Class (ED)

 Vision Services

 Structured Learning Environment

 Hearing Services

 Speech/Language

 Other

3. Reason(s) services ended

(Check appropriate boxes)

 Earned diploma

 Dropped out but earned GED

 Earned certificate

 Met legal age limit (21)

 Dropped out

 

4. Reason(s), if student dropped out

(Check appropriate boxes)

 Wanted to

 Parents wanted it

 Needed to work

 Personal problems

Was not doing well and decided to quit

 Other

School personnel recommended it

 

Educational History

5. Number of years student received special education services

              Allegany County

              Other school districts

  1-3

  1-3

  4-7

  4-7

  8-11

  8-11

  12+

  12+

6. Regular education participation

(during last school year)

  One period per day

  Four or more periods per day

  Two periods per day

  100% of the school day

  Three periods per day

 

7. The graduate's last IEP contained objectives which include:

(Check appropriate boxes)

 Academics

 Pre-vocational and/or vocational

 Functional academics

 Transitioning

 Life skills

Other agency involvement (DORS, etc.)

 Social skills

 College preparation

 Behavior intervention

 Other

8. His/her high school program included: 

(Check appropriate boxes)

 Vocational education

 Community-based learning

 Work-study

 Work-based learning/training

 Employment after school hours

 

If vocational education is checked above, please indicate program of study, for example commercial sewing, auto mechanics, printing, etc.

 

Post-Secondary Education And/Or Training

9.Education received since graduation 

(Check appropriate boxes)

 2 year community college

 None

 4 year college or university

 Other

 Adult-Education classes (non-credit)

 

10.Vocational/job training since graduation             

(Check appropriate boxes)

 Vocational/technical school

 None

 Apprenticeship program

 Other

 On-the-job training

 

Work Experience

11. Graduate's current employment status:

 Full-time (37 hours or more per week)

 Part-time

 Not employed

12. How graduate found current job             

(Check appropriate boxes)

 On his/her own

 Teacher or counselor

 Parent,guardian, other relative

 Adult Service Agency(DORS,DDA,etc)

 Employment agency

 Other

 Friend

 

13. Graduate's current occupation (Write "unemployed' if not working at this time and proceed to #21

14. Length of time employed at current job

15. Current job benefits

(Check appropriate boxes)

 None

 Vision insurance

 Sick leave

 Free meals

 Vacation

 Life insurance

 Health insurance

 Don't know

 Dental insurance

 Other

16. Graduate's current job satisfaction

 

 Very satisfied

 Not satisfied

 Somewhat satisfied

 Very unhappy

17. Graduate's monthly income from current job

18. Problems at current job           

(Check appropriate boxes)

 Doing good work

 People picking on graduate

 Working the entire day

 Boredom

 Boss being happy with graduate's work

 Other

People not talking to graduate

 No problems

19. What the graduate likes best about the current job

 The work

 The money

 The people

 Other

20. What the graduate likes least about the current job

 The work

 The money

 The people

 Other

21. Reason(s) not currently employed

(Check appropriate boxes)

 No job in the area he/she could do

 No transportation

 No one to help him/her find a job

 Health reasons

 No training available for a job

 Job too hard

 Doesn't want to give up SSDI benefits

 Couldn't get along with boss

 Laid off

 Couldn't get along with co-workers

 Quit

 Attending school

 Fired

 Other

Independent Living And Leisure Activities

22. Graduate's living arrangement

 

 Alone in his/her own home

 With spouse

 Apartment alone

 With spouse's parents

 Apartment with friend(s)

 Group home

 With parent or guardian

 Other

 With relatives

 

23. Living expenses the graduate pays

 

 All (rent, utilities, etc.)

 None

 More than half of all

 Don't know

 Half or less

 

24. Graduate's income source

(Check appropriate boxes)

 Job

 Social Security Benefits

 Spouse

 Welfare

 Parents

 Other

25. Graduate's transportation

(Check appropriate boxes)

 Drives own or parents' car

 Walks

 Bus or taxi

 Rides bike

 Relatives or friends transport

 Other

26. Community resources used most

 

 Shopping facilities

 Libraries

 Homes of friends

 Bank

 Outdoor recreation (pool, park,etc.)

 Other

 Indoor recreation (movies,bowling,etc.

 

27. Clubs/organizations participation

(Check appropriate boxes)

 Church club

 Exercise class

 YMCA

 Adult Education class

 Scouts

 Other

28. Events graduate attends

(Check appropriate boxes)

 Sporting events

 Fairs or festivals

 Concerts or plays

 Other

 Movies

 

29.Independent living activities performed

(Check appropriate boxes)

 Cooking meals or preparing snacks

 Making change

 Laundry

 Managing bank account

 Household chores

 Writing checks for purchases

 Purchasing food

 Using telephone to get information

30. Graduate is registered to vote

Yes

No

 

Adult Services

31. DORS services accessed

(Check appropriate boxes)

 Assessment and evaluation

 Vocational and other training services

 Vocational rehabilitation/counseling

 Rehabilitation technology

 Job search,placement,follow-up

 Support services

 Medical rehabilitation

 None

32. DDA services accessed

(Check appropriate boxes)

 Day habilitation

 Behavior/support services

 Community residential services

 Supported living arrangements

 Supported employment

 None

 Family/Individual support services

 

33. MHA services accessed

(Check appropriate boxes)

 Mental health evaluation/treatment

 Supported employment

 Psychiatric rehabilitation programs

 Respite care

 Residential rehabilitation programs

 None