CGA-14B Math Instruction Evaluation

U.S. Coast Guard
Academy

Math
Instructor
Evaluation

Director of Admissions (tp)
U.S. Coast Guard Academy
31 Mohegan Avenue
New London, CT 06320
800-883-8724 (phone)
860-701-6700 (fax)
www.uscga.edu
[email protected]

Privacy Act Statement. In accordance with 5 USC 552a(e)(3), the following
information is provided to you when supplying personal information to the USCG.
(1) Authority which authorizes the solicitation of the information: 14 USC 182(a).
(2) The Principal Purpose for this information is to ensure that the applicant is
basically qualified to apply for the USCGA. (3) Routine uses which may be made of
the info: As background info on applicants for the selection process. To contact the
applicant. The SSN is a basic identifier. To determine if there are existing USCG
records on the individual. In performance of the duties of officials and employees of
the USCG, in managing and contributing to the admissions program and
appointment of Cadets. (4) Disclosure of the information is voluntary, but the
applicant will not be considered further if the information is not provided.
Submissions of the Evaluator will not be disclosed to the applicant without consent.

Please provide the information requested in Section 1. On the front of a blank envelope, print the following four lines of
information: (1) Your Name; (2) The last four digits of your SSN; (3) Math Instructor Evaluation; and (4) U.S. Coast
Guard Academy. Provide this form and the envelope to your math instructor and request that the form be returned to you
in the sealed envelope. This form must be returned to the Admissions Office, along with your other supplemental
forms, by March 1st.
Section 1:
Name: _________________________________________________________

Last Four Digits of SSN: __________________

City: __________________________________________

State: _____________

Zip Code: _________________________

Telephone: ____________________________________

Email: ___________________________________________________

Section 2: The above student is applying to the U.S. Coast Guard Academy. Please complete this form and seal it in the
envelope provided by the applicant. Sign your name over the envelope seal to ensure confidentiality and return it to the
student. On the back of this form or in a separate letter of recommendation, please discuss how well this student
will: 1) Perform in a rigorous technical curriculum; and 2) Demonstrate respect and compassion toward others.
Thank you for your time and assistance.
Did you stipulate confidentiality
as a condition for providing
information? (Please circle one)
No

Low

Average

High

Please check the appropriate box:

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Do you have low, average, or
high familiarity with this
applicant? (Please circle one)

Commitment to learning and personal growth
Commitment to a healthy lifestyle
Ability to think critically
Communicates effectively face to face
Communicates effectively in written work
Takes advantage of opportunities to reach full potential
Accepts criticism and makes improvements
Adjusts to a demanding schedule of activities without neglecting school work
Exerts maximum effort showing a strong desire to achieve in every field
Sets high standards for own performance in a variety of pursuits
Consistently respects others
Takes action to include group members who are struggling or left out
Gains respect from peers
Name: ______________________________________ Title: ______________________________________________________

Signature: __________________________________

Date: _________________ Telephone: _________________________

U.S. Dept. of Homeland Security, USCG, CGA-14B (Rev. 02-08)

OMB No. 1625-0004

An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control
number. The Coast Guard estimates that the average burden for this form is 15 minutes. You may submit any comments concerning the accuracy of
this estimate or any suggestions for reducing the burden to: U.S. Coast Guard Academy, 31 Mohegan Avenue, New London, CT 06320, or Department
of Homeland Security Desk Officer, Office of Management and Budget, Office of Information and Regulatory Affairs, Washington, D.C. 20503.