Intake Questionnaire
Central Carolina Technical College
Participant Information
Name
First Name
Last Name
CID Number
Email
example@example.com
Student Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have family members that you provide care for?
Yes
No
Do you currently work 20 hours or more a week?
Yes
No
Is your employer flexible with accommodating your work schedule to meet your class schedule?
Yes
No
I am not currently working
What is your highest level of education?
Please Select
High School Diploma
GED
Associates Degree
Bachelor Degree
Other
What is your FATHER highest level of education?
Please Select
High School Diploma
Did not complete high school
GED
Some collge
Associates Degree
Bachelor Degree
Other
What is your MOTHER highest level of education?
Please Select
High School Diploma
Did not complete high school
GED
Some collge
Associates Degree
Bachelor Degree
Other
What services or support do you need assistance with? (select all that apply)
Academic Advising
Tutoring
Counseling
Financial Aid Assistance
Career Planning
Academic Development
College Tour
Transfer Planning
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Next
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Why did you choose to attend this college?
What is your current major?
Briefly explain why you choose your major.
What are you career goals after completing your major/program?
What do you see as your biggest challenge to achieving your college education and career goals?
Do you plan to transfer to a 4-year college?
Yes
No
List the top 3 schools you would like to tour.
Technology & Financial Aid Readiness Scale Rating
Instructions: Please rate your level of comfort or knowledge for each item using the scale below:
Rows
1 = Not at all comfortable / No knowledge
2 = Slightly comfortable / Limited knowledge
3 =Somewhat comfortable / Basic understanding
4 = Comfortable / Good understanding
5 = Very comfortable / Strong understanding
Using a computer (typing, saving files, navigating folders)
Using email (sending, receiving, attaching documents)
Understanding the steps required to apply for financial aid
Understanding the difference between grants and scholarships,
Understanding the difference between unsubsidze and subsidize loans
Signature
Date
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Month
-
Day
Year
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