Student's Name:

Date of form completion:

Student's age

Student's grade

Name of Person completing form

Relationship to student Mother Father Grandmother Grandfather Aunt Uncle Sister Brother Other guardian

My son/daughter freely helps with household chores Strongly Agree Agree Not Sure Disagree Strongly Disagree

My son/daughter completes chores that he/she starts Strongly Agree Agree Not Sure Disagree Strongly Disagree

My son/daughter responds positively to directions Strongly Agree Agree Not Sure Disagree Strongly Disagree

My son/daughter calmly accepts constructive criticism Strongly Agree Agree Not Sure Disagree Strongly Disagree

My son/daughter works/plays well with friends Strongly Agree Agree Not Sure Disagree Strongly Disagree

My son/daughter uses free time constructively Strongly Agree Agree Not Sure Disagree Strongly Disagree

My son/ daughter does homework without being told Strongly Agree Agree Not Sure Disagree Strongly Disagree

I hope that my son/daughter will pursue additional training/schooling after high school Strongly Agree Agree Not Sure Disagree Strongly Disagree

I hope that my son/daughter will become employed after high school Strongly Agree Agree Not Sure Disagree Strongly Disagree

I hope that my son/daughter will live on his or her own after high school Strongly Agree Agree Not Sure Disagree Strongly Disagree

Based upon your child’s interests and abilities, what jobs/careers do you think your child would enjoy and succeed in?

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Please return this completed questionnaire to your child’s teacher. THANK YOU!