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Project Life Exit Questionnaire
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1.
First Name
(Required.)
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2.
Last Name
(Required.)
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3.
DOB
(Required.)
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4.
Age
(Required.)
18
19
20
21
22
23
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5.
Gender
(Required.)
Born male/ Identify male
Born female/ Identify female
Do not identify with gender assigned at birth/ Gender fluid
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6.
Reason for exit:
(Required.)
Planned/Received 12 months of assistance
Assistance terminated by CAC due to noncompliance
Evicted by Landlord
Youth decided to terminate commitment
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7.
Does the youth have a certified birth certificate?
(Required.)
Yes
No
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8.
Does the youth have an original social security card?
(Required.)
Yes
No
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9.
Does the youth have a State Identification Card?
(Required.)
Yes
No
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10.
Does the youth have:
(Required.)
A full Driver's License
Learner's Permit or Intermediate License
Neither
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11.
Does the youth own a vehicle?
(Required.)
Yes
No
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12.
Highest level of high school education that the youth has completed:
(Required.)
9th
10th
11th
High School Diploma
Diploma equivalency (GED)
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13.
Has the youth enrolled in/completed a post-secondary educational program? (Select all that apply.)
(Required.)
No
Enrolled: short-term certificate (1 year or less)
Completed: short-term certificate (1 year or less)
Enrolled: 2- or 4-year college degree program
Completed: 2 or 4 year college degree program
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14.
Is the youth parenting or currently expecting a child?
(Required.)
No
Expecting
1 Child
2 or more children
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15.
Is the youth receiving SSI/SSDI?
(Required.)
Yes
No
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16.
Is the youth currently employed?
(Required.)
No
Part -Time
Full time (at least 30 per week)
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17.
What is the youth’s hourly wage?
(Required.)
$7.50 - $10.00
$10.00 - $15.00
$15.00 or $20.00
More than $20.00
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18.
Was the youth ever charged or convicted of a crime while in the program?
(Required.)
Yes
No
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19.
Youth housing plan upon exit
(Required.)
Remain in rental unit
Subsidized Housing Program
Unsubsidized housing
Housing Insecure ( couch surfing/homeless, etc.)
Unknown
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20.
Please elaborate on housing plan:
(Required.)
21.
Has the youth been accepted for Life Set Services upon exit from Project Life?
Yes
No