First Name
Last Name
Address
Apartment #
City
State
Zip Code
Telephone
E-mail
Gender Male     Female
   
1. Did You Graduate from High School?
Yes: No:

A. High School Attended Name
(IF YES SKIP TO QUESTION 2)
(IF NO ANSWER QUESTION B)

Question B.(IF NO)Did you

B1. Drop Out?
Yes: No:

B2. Get a GED?
Yes: No:
(IF YES CLICK HERE AND SKIP TO QUESTION B3)
(IF NO CLICK HERE AND ANSWER BB)

BB. Do you intend to get your GED?
Yes No

B3. What were the reasons why you DID NOT Graduate from High School. Please Select Reasons(Check All That Apply)
Not Enough Money so I had to Work
Bad Grades
Health Issues
No Interest in High School
Didn't Feel Like Studying
Family Responsibilities
No one I knew graduated from high school
Other Reasons, please explain:


2. Which Grades did you participate in the leadership program?(Check All That Apply)
9th Grade 10th Grade 11th Grade 12th Grade

3.Table of activities Participated in.
Activities You Participated Least Valuable Valuable More Valuable Most Valuable Extremely Valuable
Field Trips
College Tours
Homework Assistance
Support Groups/rap sessions
Workshops on Life skills awareness, character, leadership development
Community Resource information
Fundraising & Community outreach projects
After-School Recreational activities/clubs (dance, writers club, art, computers,etc...)
College Prep Classes(SAT, application fee waivers, scholarships, collage fairs & trips)
One on one advisory sessions
Stipends
Internships
Mentoring (provided by NY Junior League)


4. Did you participate in any community service projects?
Yes No

If yes, please specify:

5. Did you hold any other leadership positions in high school or in the community?
Yes No

If yes, please specify:

6. Did you go for any further education after high school?
Yes No
IF YES, ANSWER QUESTION A.
If NO, SKIP TO QUESTION 9

A. What kind of schooling/education?
Vocational/Trade school
Acting School
Community College
Cooking School
College/University
Millitary Academy
Religious Training
If Other, please specify:

 

[IF ANSWER IS COLLEGE/UNIVERSITY OR COMMUNITY COLLEGE, ANSWER QUESTIONS B THROUGH D. IF ANSWER IS ANYTHING OTHER THAN COLLEGE, SKIP TO QUESTION E.]

B. What is the name of college you attend or attended?

C. What year did you first attend?



D. Are you still attending?[IF NO, SKIP TO D2]
Yes No

D1.[IF YES]Do You Expect to graduate?
Yes No [IF NO, SKIP TO DB]

DA. [If yes] What year will you graduate?

DA1. What is your major? [IF NO MAJOR CLICK HERE]

DA2. What is your current GPA?
Check Off respondent knows exact GPA
Check Off respondent does not knows exact GPA
[SKIP TO QUESTION 7.]

DB. [IF NO:] WHY? [READ THE LIST OF REASONS BELOW. CHECK ALL THAT APPLY.]
Not Enough money
Family responsibilties
No interest in college
Grades
Health issues
Don't know wht to study
Don't fit in
Want to work
No one I know has finished college
If Other, please explain: :
[SKIP TO QUESTION 7.]

D2. IF you are not still attending college, did you graduate?
Yes    No

DC. [If Yes]What year?
SKIP TO QUESTION DE


DD.[IF NO] Why?[READ THE LIST OF REASONS BELOW. [CHECK ALL THAT APPLY],
Not Enough money
Family responsibilties
No interest in college
Grades
Health issues
Don't know wht to study
Don't fit in
Want to work
No one I know has finished college
If Other, please explain: :


DE. What was your last GPA?
Check Off respondent knows exact GPA
Check Off respondent does not knows exact GPA
DF. What was your last major?
[SKIP TO QUESTION 7.]


QUESTIONS ABOUT SCHOOLING/EDUCATION OTHER THAN COLLEGE (TRADE SCHOOL, MILITARY ACADEMY, COOKING SCHOOL)
E. What is the name of the institution you attend or attended?

F. What year did you first attend?

G. Are you still attending? Yes No [IF NO, SKIP TO G2

GA. [IF YES:] What year?

GA1. What are you studying?
[SKIP TO QUESTION 7.]

GB.[IF NO:] WHY? [READ THE LIST OF REASONS BELOW. CHECK ALL THAT APPLY.]
Not Enough money
Family responsibilties
No interest in college
Grades
Health issues
Don't know wht to study
Don't fit in
Want to work
No one I know has finished college
If Other, please explain: :

G2. IF you are not still attending your institution, did you graduate? Yes    No

GC.[If Yes]What year?

GD.[IF NO] Why?[READ THE LIST OF REASONS BELOW. CHECK ALL THAT APPLY],
Not Enough money
Family responsibilties
No interest in college
Grades
Health issues
Don't know wht to study
Don't fit in
Want to work
No one I know has finished college
If Other, please explain: :

Question 7.
Did You receive a scholarship from East Side House?
Yes No
IF YES, ANSWER QUESTION IL. IF NO, SKIP TO QUESTI0N 8.]



IL.[IF YES] How did you use the scholarship money? (READ THE LIST BELOW CHECK ALL THAT APPLY.)
Tuition
Clothes
Books
Other school expenses
Car
Housing
Other, please explain:


I2. Was the scholarship helpful to you in going to college?
Yes No



Question 8.
Did you receive any merit-based scholarships?
Yes No



Question 9.
If you did not go on to further education, do you now have any future education/career plans? Please describe.




10.Did your experience in this program have any influence on your decision of whether to go to college, based on a scale of 1 to 7, where 1 is very negative, 4 is neutral, and 7 is very positive.
If you’re not sure, say not sure.

Amount of Influence on Decision to Go to College
Activities

Very Negative No Influence Very Positive Not Sure
Field Trips 1 2 3 4 5 6 7 Not Sure



11. Please grade the usefulness of the following program activities to you. If you didn’t participate, please do not check the activities.
Activites You Participated Least Useful Useful More Useful Most Useful Extremely Useful
Preparing for college
Learning the college application process
Getting a higher SAT score
Applying for an internship/job
Understanding your school work
Learning better ways to study
Learning internship/job skills/ responsibilities
Discussing your goals
Developing skills gained from recreational activities (writing, dancing, art, sports, etc.)
Developing leadership skills (public speaking, listening, etc.)
Getting better organized
Preparing written materials, presentations, or Excel spreadsheets
Having a role model

12. Are you working now?
 Yes    No
[If YES, ANSWERQUESTION A. If NO, SKIP TO QUESTION 13.]

A. Are you working full-time or part-time?
 Fulltime    Part-time    Other

B. Where are you employed?

C. What is your job/position?

D. How long have you been with this employer?



13. Would you like to be working now?[List all choices and check all that apply.]
Yes, looking for work
No, taking a break
Yes, will work after semester over
No, raising a family
Yes, job lined up, to start soon
No, illness/health problems
Other, please explain:

14.What is your marital status? [List all choices and check all that apply.]
 Single
Married
Unmarried
Divorced
Unmarried but have live-in partner
Widowed
Separated, not divorced
Other, please explain:

15. Do you have any children?
Yes    No

16. Do you have any comments about your experiences in the program?


17. Are you in contact with other alumni from the program?
Yes    No

A. [IF YES] About how many are you in contact with [IF NO, SKIP TO QUESTION 18.]
Number Of Individuals:

B. Can you give me their names and their email address, home address, and/or phone number so we can contact them also? Whatever information you have, I would appreciate it.
Yes    No


B1. [IF YES: Fill in “Contact Table.” Ask participant for name, email address, home address, and phone number.IF NO, SKIP TO B2.]
Contact Information
Name E-mail Home Address Phone Number



B2. [IF NO] Would you please give the other alumni my name and phone number? They can contact me directly.
Yes, I WILL give them your name and phone number.
No, I WILL NOT give them your name and phone number

18. Do you mind if East Side House staff contacts you in the future to follow-up on your activities?
Yes, I mind. Do not contact me.
No, I don’t mind. Please contact me.

East Side House
337 Alexander Avenue
Bronx, NY 10454-1108
T: 718.665.5250
F: 718.585.1433