Identifying Student Needs Survey

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* 1. Have you thought about continuing your education at another college or university after completing classes at WITCC?

Yes (either you plan to, you are considering it, or you are unsure how to)

No, it is not part of my plans right now.

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* 2. What is your race or ethnicity?

Asian

African American

Black

Hispanic or Latino

Native American or Alaska Native

Native Hawaiian or other Pacific Islander

White

Multiracial or Multiethnic

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* 3. Have you ever been told by a school professional that you needed to improve your English (ELL, ELS, HSE, Remedial classes)?

Yes

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* 4. What is your assigned sex at birth

Male

Female

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* 5. What is your gender identity?

Woman

Man

Transgender

Non-conforming

Two-spirit

Non-binary

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* 6. What is your sexual orientation?

Straight

LGBTQIA2S+

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* 7. Do you need accommodations for any of the following? Check all that apply:

A mental health condition (anxiety, depression, bipolar, etc.)

A learning impairment (ADHD, Dyslexia, etc.)

A mobility impairment (pregnancy, wheelchair, walker, etc.)

A sensory impairment (vision or hearing)

No disability

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* 8. Does your religious practice(s) impact your academic participation during or around class time and school days?

Yes

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* 9. When did you earn your high school diploma or HSE/GED?

I'm still in high school.

Less than 1 year ago

1 – 2 years ago

3 -10 years ago

More than 10 years ago

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* 10. Did you have additional education support (High School counselors, tutors, expertise of family members, coach, mentor, etc)?

Yes, I found support on my own.

Yes, as part of a state or federal program (Upward Bound, Talent Search or others).

Yes, I occasionally received support.

No, but I wish I had.

No, I didn’t need it.

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* 11. Do you have a reliable method of transportation to attend your classes in person?

Yes

No, I'm not taking in person classes.

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* 12. Have you been encouraged to attend college by family or friends?

Yes

Somewhat

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* 13. Does your employer support you going to college?

Yes

Somewhat (provides some flexibility)

I don’t know.

I am not employed.

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* 14. Are you the main person responsible for the care of others in your family?

Yes

Somewhat

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* 15. Are you the main source of income for your family?

Yes

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* 16. Are you worried about having enough money for your monthly needs?

Yes

Somewhat

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* 17. While in college, will it be harder for you to provide for yourself and/or your family?

Yes

Somewhat

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* 18. Do you have health insurance?

Yes, I am covered by my employer or a family member.

Yes, I am covered by a government plan (Medicaid, Medicare, CHIP, Iowa Total Care, Nebraska Total Care, etc.).

Yes, I have purchased an insurance outside of my employer.

No, I can’t afford insurance.

I don’t know.

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* 19. Do you have a doctor whom you see regularly?

Yes, I have the same doctor (or medical professional) for my annual checkups and occasional visits.

No, I rely on available doctors at the clinic I attend.

No, I rely on urgent care medical professionals.

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* 20. Does your health make your participation in school harder (pregnancy, struggle with mental health or physical conditions)?

Yes

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* 21. Are you able to focus on your studies at home?

Yes

Somewhat

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* 22. Are you homeless or at risk of being homeless?

Yes

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* 23. First Name

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* 24. Last Name

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* 25. Student ID

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* 26. What is your date of birth?

Date of birth

Date

Identifying Student Needs

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* 1. Have you thought about continuing your education at another college or university after completing classes at WITCC?

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* 2. What is your race or ethnicity?

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* 3. Have you ever been told by a school professional that you needed to improve your English (ELL, ELS, HSE, Remedial classes)?

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* 4. What is your assigned sex at birth

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* 5. What is your gender identity?

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* 6. What is your sexual orientation?

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* 7. Do you need accommodations for any of the following? Check all that apply:

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* 8. Does your religious practice(s) impact your academic participation during or around class time and school days?

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* 9. When did you earn your high school diploma or HSE/GED?

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* 10. Did you have additional education support (High School counselors, tutors, expertise of family members, coach, mentor, etc)?

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* 11. Do you have a reliable method of transportation to attend your classes in person?

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* 12. Have you been encouraged to attend college by family or friends?

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* 13. Does your employer support you going to college?

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* 14. Are you the main person responsible for the care of others in your family?

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* 15. Are you the main source of income for your family?

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* 16. Are you worried about having enough money for your monthly needs?

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* 17. While in college, will it be harder for you to provide for yourself and/or your family?

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* 18. Do you have health insurance?

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* 19. Do you have a doctor whom you see regularly?

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* 20. Does your health make your participation in school harder (pregnancy, struggle with mental health or physical conditions)?

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* 21. Are you able to focus on your studies at home?

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* 22. Are you homeless or at risk of being homeless?

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* 23. First Name

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* 24. Last Name

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* 25. Student ID

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* 26. What is your date of birth?

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* 27. Is there any specific topic of this survey that you would like to discuss with your WITCC student support team?