Name: _____________________ K-State EID: ______________ Student Cell Phone Number: _____________________
Student Questionnaire (rev. 04/18/2016)
Please complete the following form so your academic counselor can better understand your needs. Keep in mind the
answers you provide will be kept confidential.
On a scale of 1-5, 1= needs improvement, 5= confident in this skill, please rate each of the following:
Math abilities _____
Study and homework skills ________
Working to go above and beyond _____
Motivation to do well _______
Organization skills _____
College student readiness ______
Seeking help when needed _____
Self-discipline ________
Being on time, follow through, deadlines _____
Test taking skills ________
General Questions Circle Y for Yes and N for No.
Y N
I’m still currently attending school and not available by phone during the day
Y N
I plan to live on campus. If no, where do you plan on living: ______________________
Y N
I am a first generation college student (Parent has not graduated from 4 year College).
YN
I am a nontraditional student (married, over 25, have a child, or military).
Y N
I have personal/health concerns that you should be aware of (ADHD, test anxiety, depression, disability, etc.).
Yes, please explain_______________________________________________________________________________
Y N
I have an EID and password and I know what they are.
Y N
I am interested in participating in extracurricular activities (Greek life, clubs, organizations, etc.).
Y N
I have completed the FAFSA.
Y N
I would prefer to work while in school.
YN
I must work to earn money for living expenses.
YN
I prefer early morning classes.
YN
I am an out-of-state student.
Academic Questions
Y N
I have decided on a major. It is __________________________.
How sure are you of your choice of major?
Very Sure
Pretty Sure
Not Sure
Y N
I am interested in completing a minor: _______________________________.
YN
I have completed the math placement test. My score was: _________.
YN
I took the ACT. My Score was: _____________. or I took the SAT. My Score was: ____________.
My high school GPA was: ___________. or I took the GED. My score was: _________.
YN
I had an IEP in high school. If yes, please specify what for __________________________________________.
YN
I have taken courses for college credit, if so, list here: _____________________________________________.
YN
I have requested a transcript be sent to KSU.
Provide short answers to each of the following questions. If you need more space please use a separate sheet of paper.
1. Why are you going to college?
2. Who or what motivates you to do your best?
3. If you didn’t go to K-State, what would you have done next year instead?
4. Looking back at your time in high school, what is something you are proud of?
5. Looking back at your time in high school, what is something that you wish you had done differently?
6. What are some subjects that you enjoy the most?
7. What are some subjects that you struggle with?
8. Did you take any classes for college credit? Please list them here.
9. What is your biggest concern about going to college?
10. What is one thing you want your Academic Counselor to know about you academically or personally?
11. What are some struggles you may face that may hinder your success at K-State? (Financial aid, parental support,
personal issues, academic challenges, etc.)
12. What classes are you interested in taking your first semester at K-State?