Javits Student Application Report

ATTACHMENT F

Form Approved

OMB No. 1840-0781

Expiration Date: XX/XX/XXXX

UNITED STATES DEPARTMENT OF EDUCATION

OFFICE OF POSTSECONDARY EDUCATION

JACOB K. JAVITS ANNUAL STUDENT ACTIVITIES REPORT

[INSERT FISCAL YEAR]

Instructions: For [insert year] Cohort Javits fellows funded from September 1, [insert year] through August 31, [insert year], please enter all of the information requested below.

1) Student’s Name: _________________ __________________

First Name Last Name

2) Mailing Address:

Current Mailing Address:

Permanent Mailing Address:

3) E-Mail Address: ____________________________________

4) Race: ______ American Indian or Alaska Native

______ Asian

______ Black or African American

______ Native Hawaiian or Other Pacific Islander

______ White

5) Ethnicity: ______ Hispanic or Latino

______ Not Hispanic or Latino

6) Gender: ______ Female ______Male

7) Institution Name: _________________________________________

8) Year and term you entered institution’s graduate program:

_______Year _______Term (i.e., Fall Term/ Spring Term)

9) Please select one of the options shown below to denote the graduate degree program that you are pursuing in the space provided.

Degree Program: ______ 2-year MFA (Master of Fine Arts) degree

______ 3-year MFA (Master of Fine Arts) degree

______ PhD

10) Please indicate your current academic status by selecting the applicable status

for either the MFA Degree or PhD Degree classification areas.

MFA: ______Completed 1st Year Coursework
______Completed 2nd Year Coursework
______Completed Thesis/Portfolio/Performance or

recital

PhD: ______Enrolled but not yet advanced to PhD Candidacy
______Passed preliminary exams and advanced to PhD

11) Your Expected Date of Graduation: _________Month __________Year

12) Total Number of Years You Received Javits Funds: __________________

13) Describe the research activities, teaching experience or other activities in which

you have participated during the past year.

14) Please provide specific examples of conferences you have attended and

publications that you have presented during the past year:

15) If you were engaged in a part-time work experience during the past year, please

indicate the type of employment: ________________________________________

___________________________________________________________________

Please discuss briefly your part-time work experience.

16) If you took an Interruption of Study, please indicate the purpose of the

Interruption and discuss the activities in which you participated.

17) Please discuss your current goals and employment plans upon earning your

degree.

18) Have you submitted the FAFSA for the [insert year] – [insert year] academic year?

_____ Yes _____ No

19) Please explain the impact that receiving a Javits fellowship had upon your

decision to enter graduate school:

20) Please explain the impact that receiving a Javits fellowship had upon your

choice of academic area at your institution:

21) At the time you were awarded a Javits fellowship, did you have other fellowship

offers?

____ Yes ____ No

If “Yes,” please specify which offers you had below:

If “Yes,” please explain what made you decide to accept the Javits fellowship

over your other fellowship offers:

DISCLOSURE OF BURDEN STATEMENT

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 1840-0781 and the expiration date is XX/XX/XXXX. The time required to complete this information collection is estimated to average 3 hours per response, including the time to review instructions, search existing data resources, gather needed data, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate (s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC 20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: The Jacob K. Javits Fellowship Program, U.S. Department of Education, 1990 K Street, N.W., Washington, DC 20006-8521.