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 Office of Diversion and Transition Programs 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 Emotional/Behavior Disorder Speech/language Impairment Deaf/Blindness Deafness Hard of Hearing Specific Learning Disability Moderately Mentally Impaired Mild Mental Impairment Severe Mental Impairment Other Health Impairment Orthopedic Impairment Developmental Delay Blindness and Low Vision Traumatic Brain Injury
Reason for Exit	*	Graduated: Standard Diploma Graduated: Modified Diploma Dropped Out Reached Maximum Age of 21 Modified: returned for services

WVDE-ISS-060
Revised 4/1/16

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