IMPACT SURVEY

Developed by Drs. Richard Gacka and Sherry Royce

1. Your Education

LEVEL of EDUCATION Before attending ABLE Program While attending ABLE Program After leaving ABLE Program
Dropped out High School      
Obtained GED      
Certificate or non degree      
Associate Degree      
Bachelors Degree      
Masters Degree      
Doctorate      
Company provided training      
Military      
Personal Interest Courses      

2. Your Family Status

STATUS LENGTH OF TIME # CHILDREN
Y or N if Problems		 CURRENT STATUS
(Divorced/Separated)
Single Never Married      
Marriage 1      
Marriage 2      
Marriage 3 or more      

3. Your Children's Education:   Pre-K: _____________

# K-6 # Completed HS #In HS # Dropped out HS #Received GED
         
# Some College # Completed College #In College # Masters Degree # Advanced Degree
         

4. Your Current Activities

box iconActive in church

box iconAthletics or Exercise

box iconComputer User

box iconActive in
ABLE program

box iconActive in social organizations

box iconActive with school or college

box iconMentor, Tutor or Teacher

box iconParticipate in
Self Help groups

box iconActive in Coaching

box iconActive in
Band or Choir

box iconOutdoor Activities

box iconGardening

box iconActive in Fraternal group

box iconHobbies or Crafts

box icon 

box icon 

Adult Learner Code:_________ Interviewer’s Initials: ______ Interview Date______

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