Exit Survey Follow-up

* = required field

I am...	*	the student the student's parent/guardian county personnel
Student First Name	*
Student Middle Initial
Student Last Name	*
Student Maiden Name
WVEIS ID	*
County	*	Barbour Berkeley Boone Braxton Brooke Cabell Calhoun Clay Doddridge Fayette Gilmer Grant Greenbrier Hampshire Hancock Hardy Harrison Jackson Jefferson Kanawha Lewis Lincoln Logan Marion Marshall Mason McDowell Mercer Mineral Mingo Monongalia Monroe Morgan Nicholas WV School of Diversion and Transition Ohio Pendleton Pleasants Pocahontas Preston Putnam Raleigh Randolph Ritchie Roane Summers Taylor Tucker Tyler Upshur Wayne Webster Wetzel Wirt Wood WV Schools for the Deaf and Blind Wyoming
School	*	Select a county first.
Birthdate	*
Eligibility/Exceptionality	*	Autism Blindness and Low Vision Deaf/Blindness Deafness Emotional/Behavior Disorder Hard of Hearing Intellectual Disability, Mild Intellectual Disability, Moderate Intellectual Disability, Severe Orthopedic Impairment Other Health Impairment Specific Learning Disability Speech/language Impairment Traumatic Brain Injury
Reason for Exit	*	Graduated: Standard Diploma Graduated: Alternate Diploma Dropped Out Dropped Out for employment Reached Maximum Age of 21

WVDE-ISS-060
Revised 4/1/16

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