Exit Survey

* = 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	*
Gender	*	Female Male
Race/Ethnicity	*	Hispanic/Latino American Indian or Alaska Native Asian Black or African American Native Hawaii and Pacific Islander White Two or More Races
Birth Date	*
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.
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: Returning for services

WVDE-ISS-060
Revised 2/5/16

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