Student Support Services (SSS) Intake Questionnaire
Central Carolina Technical College
PARTICIPANT
Name
*
First Name
Last Name
CID Number
*
MyCCTC Email
*
example@example.com
Student Phone Number
*
(999)999-9999
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
PARENT EDUCATION LEVEL
What is your FATHER highest level of education?
*
Please Select
Did Not Complete High School
High School Diploma/GED
Some College (No Degree)
Associate Degree
Bachelor's Degree
Other
What is your MOTHER highest level of education?
*
Please Select
Did Not Complete High School
High School Diploma/GED
Some College (No Degree)
Associate Degree
Bachelor's Degree
Other
SERVICES / NEEDS
What services or support do you need assistance with? (select all that apply)
*
Academic Advising
Academic Counseling
Academic Tutoring
Career Counseling/Transfer Information
Career Exploration
Career Planning
College Tour/Information
Computer Lab /Printing
Cultural Activity /Information
Financial Aid Assistance
Personal Counseling
Other
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?
*
TRANSFER /COLLEGE TOURS
Do you plan to transfer to a 4-year college?
*
Yes
No
List the top 3 schools you would like to visit.
Rows
School
1
2
3
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
1. Using a computer (typing, saving files, navigating folders)
2. Using email (sending, receiving, attaching documents)
3. Understanding the steps required to apply for financial aid
4. Understanding the difference between grants and scholarships,
5. Understanding the difference between unsubsidized and subsidize loans
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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*
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