4-11 Month Follow Up Form

Intervention End Date *
Intervention End Date
First Attempt to Contact
First Attempt Date
First Attempt Date
Second Attempt to Contact
Second Attempt Date
Second Attempt Date
Third Attempt to Contact
Third Attempt Date
Third Attempt Date
Survey
We would like to know your opinion about the program you participated in. The next set of questions ask how much you agree or disagree with each statement. The possible answers range from 1 to 5. 1 means you strongly disagree with the statement. 2 means you disagree. 3 means your opinion is neutral, that you do not disagree or agree with the statement. 4 means you agree with the statement. 5 means you agree strongly. There are five statements. Please circle the number that is closest to how much you agree or disagree with each statement in the table below.
What credentials did you earn while participating in this program?
(If you are not working, please write in 0, if you prefer not to answer, please leave this field blank)
(If you are not working please write in $0, if you prefer not to answer, please leave this field blank)
$
(If you have not been offered a job, please write in 0, if you prefer not to answer or are currently employeed, please leave this field blank)
(If you have not been offered a job, please write in $0, if you prefer not to answer or are currently employed, please leave this field blank)
$