Student Retention Assessment Form
Use this form to assess factors affecting student retention and identify support needs.
Student Overview
Student Name
*
First Name
Last Name
Student Email
*
example@example.com
Student Reference Code
Program / Major
*
Current Academic Level / Year
*
First Year
Second Year
Third Year
Fourth Year
Graduate
Other
Current Enrollment Status
*
Full-time
Part-time
Leave of Absence
Not Currently Enrolled
Other
Retention Assessment
Overall likelihood of staying enrolled this term
*
Very unlikely
1
2
3
4
Very likely
5
1 is Very unlikely, 5 is Very likely
Primary factors affecting retention
*
Academic workload
Finances
Schedule conflicts
Transportation
Housing
Belonging/community
Advising/support
Career concerns
Personal reasons
Other
Satisfaction with academic support
*
Very dissatisfied
1
2
3
4
Very satisfied
5
1 is Very dissatisfied, 5 is Very satisfied
Satisfaction with advising and mentoring
*
Very dissatisfied
1
2
3
4
Very satisfied
5
1 is Very dissatisfied, 5 is Very satisfied
Sense of belonging on campus
*
Very low
1
2
3
4
Very high
5
1 is Very low, 5 is Very high
Likelihood of recommending the institution to peers
*
Not at all likely
0
1
2
3
4
5
6
7
8
9
Extremely likely
10
0 is Not at all likely, 10 is Extremely likely
Support Needs and Follow-up
What support would help most?
*
Tutoring
Academic advising
Financial aid guidance
Counseling or wellness support
Career services
Schedule flexibility
Peer mentoring
Other
Preferred time to be contacted
Please Select
Morning
Afternoon
Evening
Any time
Preferred contact method
*
Email
Phone
Text message
In person
Additional comments or suggestions
Submit Assessment
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