Personal Success Plan: Initial Survey

 This survey is designed to help us understand your thoughts about your growth and development during your career as a student at Defiance College.   Please answer these questions openly and honestly.

Please note when filling out this form: Use the Tab Key to switch from question to question, or use your mouse. Hitting the Enter Key will submit the form.

First Name   Middle Name
Last Name   Preferred Name
Mailing Address
City State Zip/Postal Code
Home Phone     Email  

Do you have any disabilities that may restrict your performance in classes, of which the college should be aware? (i.e. hearing impairments, dyslexia, etc.)

What is the highest level of education your parents have attained? (Please choose only one box for each parent.)
Less than a high school graduate
High school graduate
Some college/vocational school
Bachelor’s degree
Master’s degree
Doctoral degree (including law or medical degree)
Don’t Know
Other - Please specify

What day will you be attending Orientation?


Educational Plans & Intellectual Development
What is your major? (If still deciding, write “undecided.”)
How certain are you of your choice of an academic major (check one)?
Very Sure Fairly Sure Still Deciding No Major Yet

What led you to choose your major?

What high school academic subjects did you find most interesting?

What high school academic subjects did you find least interesting?

What are your biggest concerns about your ability to excel in college?

Professional & Vocational Development
What do you want to do after you graduate with your degree from Defiance College? (List more than one option if you have several ideas).

Have you thought about graduate school (especially if you are a pre-professional major)? If so, what type of graduate school and where would you like to attend?

What groups of people do you most want to serve within your future profession?

What would be your dream career?

What additional information would you like us to know about you?

Educational Assistance and Needs:

This section presents several topics or issues in which you may need assistance. Please indicate those areas you need help in or are interested in by checking the “yes” box. If you are not interested in the activities, check the “no” box.

 I need help in: Yes No
Deciding my educational career/plans
Expressing my ideas in writing
Improving my reading speed/comprehension
Improving my study skills
Improving my math skills        
Expressing my ideas by speaking
Reducing my anxiety before/during an exam
Reading/learning disability
Goal Setting and Academic Motivation 
Time Management
Note Taking
I would like to enroll in the Academic Monitoring Program.
By checking the box above, a student elects to be enrolled in the academic monitoring program through the office of Student Academic Support Services. This means a SASS member will meet with the student at the 4-week, 8-week, and 12-week point of each semester to discuss academic progress. Any student can self-select to be monitored.

Co-Curricular Activities:

What co-curricular activities did you participate in during high school (clubs, teams, organizations, music, drama, etc.)?

In which Co-Curricular Activities do you plan to participate at DC?
Academic Associations or Clubs Fraternities or Sororities Religious Activities  
BASA (Black Action Student Association) Intramural Sports Student Government  
Cheerleading Marching and/or Pep Band CAB (Campus Activities Board)  
Peer Leader/Mentor Theater Honors Program  
Community Service/Outreach Vocal/Choral Music The Defender (Newspaper)  
Club Wrestling International or Domestic Travel Progeny (literary magazine)  
PULSE (Peers Understanding Leadership & Social Education)  
Do you plan to be involved in Intercollegiate Sports? Yes No
If yes, in which Intercollegiate Activities do you plan to participate?
Baseball Golf Swimming and Diving
Basketball Lacrosse Tennis
Cross-Country Soccer Track and Field
Football Softball Volleyball
Club Wrestling