Project Independence Aftercare Survey
Participant's Name
First Name
Last Name
Date You Exited the PI Program
-
Month
-
Day
Year
Date
Did you successfully complete the program?
Yes
No
Did you voluntarily leave the PI program?
Yes
No
Were you terminated from the program?
Yes
No
Where do you and/or your child(ren) currently live?
On your own
Relative
Shelter
Other
If you marked "Other," please explain your living arrangement.
Do you currently receive public assistance? (Please check all that apply)
WIC
Food Stamps
TANF
Do you have your GED?
Yes
No
When did you receive your High School Diploma or GED
Before the PI Program
During the PI Program
After leaving the PI Program
I do not have my High School Diploma/GED
Are you currently enrolled in college?
Yes
No
Are you currently enrolled in a certificate or other educational program?
Yes
No
If yes, please enter the name of your school and what you are studying/ or the name of your certificate program:
Are you currently employed?
Yes
No
If so, name of employer, hours per week, pay per hour and length of time on job:
Please mark any of the following services for which you or your child need assistance: (Please check all that apply)
Medical (dental, physical, optical, mental)
Education
Employment
Legal
Is there anything the PI program can do to assist you?
Would you recommend the PI program to a friend?
Yes
No
If you answered "Yes," please share how PI helped you the most.
Do you have any recommendations to improve the PI program?
Address (if available)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Submit
Should be Empty: