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Foster Youth Exit Survey Logging
Survey
What is today's date?
What is the youth's first name?
*
What is the youth's last name?
*
What is the youth's date of birth?
What is the youth's age?
What is the youth's email address?
What is the youth's race?
African American/Black
Hispanic/Latino/Latina
Caucasian/White
American Indian/Native American
Asian
Other
If Other, please specify:
What type of placement is the youth CURRENTLY in?
Foster Home
Residential Program
Relative Placement
Pre-Independent Living Program
Independent Living Program
AWOL
Other
For what reason is the youth leaving state's care?
Decided not to extend commitment at 18
Voluntarily decided to end commitment after 18
Commitment being terminated by DCBS due to noncompliance
Transitioning to Supported Community Living (SCL)
Aging out at 21
AWOL at 18
Other
Survey Completed By:
Youth
Staff
Where will the youth be living upon exit?
With Relative
With Nonrelative
Own apartment
College dorm or housing
Jail
SCL Placement
Unknown
Other
If Other:
If youth will be living in own apartment, did they obtain apartment through a subsidized program?
Yes
No
If Yes, which one? (Scholar, Project Life, Etc.)
Did the youth leave state’s care at any point after turning 18 and later request to return to care?
Yes
No
Does the youth have children or are they expecting a child?
Yes
No
If youth has children, with whom will the children be living when the youth exit’s care?
What is the highest grade the youth has completed?
Has the youth earned a postsecondary credential or certificate?
Yes
No
If yes, which one?
Is the youth currently attending an educational program?
Yes
No
If yes, what type of program (high school, GED program, college, vocational program, etc.)?
If the youth is currently in college, what is their classification.
Has the youth ever been charged with a crime as an ADULT?
Yes
No
Does the youth currently have a bank account?
Yes
No
Approximately how much money does the youth have saved in all places?
Is the youth currently employed?
Yes
No
If yes, How long has the youth been employed at their CURRENT job?
If yes, is the youth working full-time or part-time?
Full Time
Part Time
If yes, Is the youth earning more than the state minimum wage per hour ($7.25)?
Yes
No
Does the youth have an original birth certificate, social security and a state issued ID?
Yes
No
Does the youth have a Driver’s License?
Yes
No
If no, does the youth have Driving Learner’s Permit?
Yes
No
Did the youth complete a Driver’s Education course?
Yes
No
What is the youth’s primary mode of transportation?
Public Transportation
Personal Vehicle
Other People
Uber
Other
Is the youth currently taking any psychotropic medications?
Yes
No
If yes, do you plan to continue taking medication after leaving care?
Yes
No
Does youth feel prepared to live independently (pay your own bills etc.)?
Yes
No
Unknown
Why or why not?
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