1.

Age:

◯ 12 and Below ◯ 13-15 ◯ 16-18 ◯ 19 and Above

2. Gender:

◯ Male ◯ Female ◯ Others___________

3. Are you currently enrolled?

◯ Yes ◯ No
4. Current grade level or grade level you dropped out?

◯ Grade 7 ◯ Grade 8 ◯ Grade 9 ◯ Grade 10

Select and shade the correct circle on whether you Strongly Agree, Agree, Neutral, Disagree, or Strongly
Disagree on these statements.

5. These factors are the primary reasons high school student drop out of junior high school:

Strongly Agree Agree Neutral Disagree Strongly

Disagree
Academic
difficulties
Lack of support
from teachers or
staff
Family
responsibilities
(e.g., caring for
siblings, financial
support)
Peer pressure or
bullying
Mental health
issues
Substance abuse
Lack of interest
or engagement
in school

Strongly Agree Neutral Disagree Strongly

Agree Disagree
6. If still
enrolled,
have you
considered
dropping
out of
junior high
school