Louis Stokes Alliances for Minority Participation (LSAMP) Distance Monitoring Bridge Survey

Appendix A2
LSAMP Bridge to the Doctorate Data Collection Screens

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LOUIS STOKES ALLIANCES FOR MINORITY PARTICIPATION

Bridge to the Doctorate Program

Annual Survey

Welcome
Welcome to LSAMP BD Web, the online data reporting system for the Louis Stokes Alliances for Minority Participation Bridge to
the Doctorate Initiative. LSAMP BD Web allows you to provide the National Science Foundation (NSF) with reliable annual data.
To enter LSAMP BD Web, please enter your institution's unique user ID and password in the boxes below and click on Login.

Login
User ID:
Password:
Login

Password trouble?

The system is closed for maintenance each Wednesday from 5:30 p.m. to 7:30 p.m. eastern time.
Notice: The system will log you out after 1 hour of inactivity. If you are logged out, you will need to reenter your user ID and
password to return to LSAMP BD Web.
DID YOU FORGET YOUR USER ID OR PASSWORD?
Enter your e-mail address below and click on Submit. We will send your user ID and password to you.
E-mail:

Submit

This feature is available only if you have previously logged in to LSAMP BD Web and provided us with your e-mail address. If
you did not receive any login information or have not yet provided us with your e-mail address, please e-mail us at
[email protected] or call toll free at (866) 227-7127.
LSAMP BD INITIATIVE DESCRIPTION
The LSAMP BD Initiative funds the initial 2 years of graduate study at LSAMP Alliance institutions. This activity will broaden
participation through the attraction of underrepresented minority students in science, technology, engineering, and
mathematics (STEM) disciplines.
SURVEY PRIVACY
Information from this data collection system will be retained by the NSF, a Federal agency, and will be an integral part of its
Privacy Act System of Records in accordance with the Privacy Act of 1974 and maintained in the Education and Training
System of Records 63 Fed. Reg. 264, 272 (January 5, 1998). These are confidential files accessible only to appropriate NSF
officials, their staffs, and their contractors responsible for monitoring, assessing, and evaluating NSF programs. Only data in
highly aggregated form, or data explicitly requested as "for general use," will be made available to anyone outside of the NSF
for research purposes. Data submitted will be used in accordance with criteria established by NSF for monitoring research and
education grants, and in response to Public Law 99-383 and 42 USC 1885c. The Social Security number (SSN) will be
maintained in accordance with the requirements of the Privacy Act of 1974. Submission of the SSN is voluntary. It is used for
survey quality control, program evaluation, and matching with other datasets maintained in the Education and Training
System of Records 63 Fed. Reg. 264, 272 (January 5, 1998).
PUBLIC BURDEN

Submission of the requested information is voluntary. Failure to provide full and complete information, however, may reduce
the possibility for continuing support through the award/project subject to this survey. Pursuant to 5 CFR 1320.5(b), an agency
may not conduct or sponsor, and a person is not required to respond to an information collection unless it displays a valid
Office of Management and Budget (OMB) control number. The OMB control number for this collection is 3145-0136. The public
reporting burden for this collection of information is estimated to average 20 hours per award, including the time for reviewing
instructions. Each principal investigator's average reporting burden is 20 hours. Send comments regarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing this burden, to Suzanne Plimpton,
Reports Clearance Officer for OMB Collection 3145-0136 LSAMP Program, National Science Foundation, 4201 Wilson Blvd.,
Suite 295, Arlington, VA 22230.

OMB# 3145-0136
LSAMP Program
< Insert New Date >

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LOUIS STOKES ALLIANCES FOR MINORITY PARTICIPATION

Bridge to the Doctorate Program

Annual Survey

July 1, 2006–June 30, 2007

ZQRC Test University YX | Logout

Welcome
1. Respondent Contact Info

Main Menu » BD Students » Student Menu » Baseline Data

2. Student Data
3. Final Submission
Help & Instructions
Print My Data

Baseline Data
STUDENT: MARIE BARRON

Previous name

Download My Data
Add Comments/Feedback
Contact Us

(If the student's last name has changed since attaining the baccalaureate degree)

LSAMP institution (the student was enrolled in)
Arkansas State University

Survey last modified
March 29, 2007

LSAMP alliance (the institution was associated with)
Mid-South

OMB# 3145-0136
LSAMP Program
< Insert New Date >

Social Security number

Student ID at the Institution

Gender

j Female n
k
l
m
i Male n
j
k
l
m
n
j Not reported
k
l
m
Ethnicity
Not Hispanic or Latino

Race (choose one or more)

c American Indian or Alaska Native
d
e
f
g
c Asian
d
e
f
g
b Black or African American
c
d
e
f
g

c Native Hawaiian or Other Pacific Islander
d
e
f
g
c White
d
e
f
g
c Not reported
d
e
f
g
Disability (choose one or more)

c Hearing impairment
d
e
f
g

c Mobility or orthopedic impairment
d
e
f
g

c Visual impairment
d
e
f
g
c Other (please specify):
d
e
f
g
c None
d
e
f
g
c Not reported
d
e
f
g
Citizenship
U.S. Citizen/U.S. National
If "Other" is selected, please specify:

Date of bachelor's degree
Month: June

Year: 2005

Undergraduate major (choose one or more)

b Agricultural Science
c
d
e
f
g
b Chemistry
c
d
e
f
g
b Computer Science
c
d
e
f
g
b Engineering
c
d
e
f
g
b Environmental Science
c
d
e
f
g

b Geosciences
c
d
e
f
g
b Life/Biological Sciences
c
d
e
f
g
b Mathematics
c
d
e
f
g
b Physics/Astronomy
c
d
e
f
g

c Other (please specify):
d
e
f
g
Undergraduate GPA
3.7

Undergraduate GPA Scale

i 4 Point scale
j
k
l
m
n

j 5 Point scale
k
l
m
n

LSAMP Level I or II status

i Level I
j
k
l
m
n

j Level II
k
l
m
n

Research experience during the undergraduate program?

j Yes
k
l
m
n
i No
j
k
l
m
n
GRE scores
Verbal:
Quantitative:
Analytical:

Date entered the STEM graduate program
Month: -- Choose one

Year: 2004

Date began receiving BD funding
Month: January

Year: 2004

Graduate work prior to receiving LSAMP BD funding
Did this student complete any graduate work before receiving LSAMP BD
funding?

i Yes
j
k
l
m
n
j No
k
l
m
n
If yes, please provide the following data:
Broad field area
Education

If "Other" is selected, please specify:

Field
Physical education/coaching

Degree
Master's (including M.B.A.)

If "Other" is selected, please specify:

Date degree awarded
Month: May

Year: 2005

If no prior graduate degrees please provide the number of graduate credits
completed prior to receiving LSAMP BD funding 0

Teaching assistantship awarded prior to receiving LSAMP BD funding?

i Yes
j
k
l
m
n

j No
k
l
m
n
j Not applicable
k
l
m
n
Research assistantship awarded prior to receiving LSAMP BD funding?

j Yes
k
l
m
n
j No
k
l
m
n
i Not applicable
j
k
l
m
n

Save

Cancel

Skip navigation
LOUIS STOKES ALLIANCES FOR MINORITY PARTICIPATION

Bridge to the Doctorate Program

Annual Survey

July 1, 2006–June 30, 2007

ZQRC Test University YX | Logout

Welcome
1. Respondent Contact Info

Main Menu » BD Students » Student Menu » Annual Data

2. Student Data
3. Final Submission
Help & Instructions
Print My Data

Annual Data
MARIE BARRON

Graduate program

Download My Data
Add Comments/Feedback
Contact Us

Intended broad major area
-- Choose one --

Survey last modified
March 29, 2007

If "Other" is selected, please specify:

OMB# 3145-0136
LSAMP Program
< Insert New Date >

Intended major
-- Choose one

Intended degree (choose one or more)

c No specific degree or certificate
d
e
f
g
c Postbaccalaureate certificate
d
e
f
g
c Master's (including M.B.A.)
d
e
f
g

c Post-Master's certificate
d
e
f
g
c Doctorate (Ph.D., D.S.C., D.Sc., Ed.D.)
d
e
f
g
c Other professional degree (J.D., L.L.B., Th.D., M.D, D.D.S., etc.)
d
e
f
g
c Other (please specify):
d
e
f
g
Amount of support received during the current reporting period (July 1,
2006–June 30, 2007)

Disbursement method
-- Choose one

Is the stipend or payment based on academic performance

j Yes
k
l
m
n
j No
k
l
m
n
Did the LSAMP BD funding end for this student during the current reporting

period (July 1, 2006–June 30, 2007)?

j Yes
k
l
m
n
j No
k
l
m
n
If yes, please provide the date funding ended.
Month: -- Choose one

Year: -- Choose one

Number of graduate course credits completed during the current reporting
period (July 1, 2006–June 30, 2007)

Teaching assistantship awarded during the current reporting period (July 1,
2006–June 30, 2007)

j Yes
k
l
m
n
j No
k
l
m
n

j Not applicable
k
l
m
n
Research assistantship awarded during the current reporting period (July 1,
2006–June 30, 2007)

j Yes
k
l
m
n
j No
k
l
m
n

j Not applicable
k
l
m
n
Year entered Ph.D. track (please use the definition below)
(completed 2 years of graduate coursework, equivalent to M.A. or M.S. and entered third
year of graduate coursework, i.e., post M.S. and into Ph.D. track)
-- Choose one

Thesis proposal - date approved (thesis not required)
Month: -- Choose one

Year: -- Choose one

Master's degree - date awarded
Month: -- Choose one

Year: -- Choose one

Ph.D. qualifying examinations - date passed
Month: -- Choose one

Year: -- Choose one

Ph.D. candidacy - date attained
Month: -- Choose one

Year: -- Choose one

Dissertation defense - date passed
Month: -- Choose one

Year: -- Choose one

Doctoral dissertation - date approved
Month: -- Choose one

Year: -- Choose one

Doctoral degree - date awarded

Month: -- Choose one

Year: -- Choose one

Doctoral dissertation abstract

Did the student receive post-LSAMP BD funding to continue graduate
studies during the current reporting period (July 1, 2006–June 30, 2007)?

j Yes
k
l
m
n
j No
k
l
m
n
If yes, please provide the funding source.
-- Choose one

Did the student leave the program or drop out during the current reporting
period (July 1, 2006–June 30, 2007)?

j Yes
k
l
m
n

j No
k
l
m
n
Date left or dropped out
Month: -- Choose one

Year: -- Choose one

If he or she left, was it to continue the Ph.D. elsewhere?

j Yes
k
l
m
n
j No
k
l
m
n
j Do not know
k
l
m
n
If yes, please provide the following information:
Transfer date Month: -- Choose one

Year: -- Choose one

Institution name

Permanent Contact Information
Please provide the permanent contact information for this student.

Student's personal e-mail address

(other than his or her current school address, if available)

Address

City

State
(If address is not in the United States, select "Non-U.S.")
Choose one

ZIP Code

Country

Phone (xxx-xxx-xxxx)

Ext.

Other Contact Information
Name and address (U.S. postal and e-mail) of a person likely to know how to reach this
student after he or she graduates.

Name

Relationship to this student

E-mail address

Address

City

State

(If address is not in the United States, select "Non-U.S.")
Choose one

ZIP Code

Country

Phone (xxx-xxx-xxxx)

Save

Cancel

Ext.

Skip navigation
LOUIS STOKES ALLIANCES FOR MINORITY PARTICIPATION

Bridge to the Doctorate Program

Annual Survey

July 1, 2006–June 30, 2007

ZQRC Test University YX | Logout

Welcome
1. Respondent Contact Info

Main Menu » BD Students » Student Menu » Followup Data

2. Student Data
3. Final Submission
Help & Instructions
Print My Data
Download My Data
Add Comments/Feedback
Contact Us

Followup Data
MARIE BARRON

Postdoctorate appointment
Has the individual received a postdoctorate appointment?

j Yes
k
l
m
n
j No
k
l
m
n

Survey last modified
March 29, 2007

If yes, please complete the following items:
Date

OMB# 3145-0136
LSAMP Program
< Insert New Date >

Month: -- Choose one

Year: -- Choose one

Institution
Department
Field

Current Employment
Is the individual currently employed?

j Yes
k
l
m
n
j No
k
l
m
n
If yes, please answer the following questions about this individual's main
job:
When did the individual begin this job?
Month: -- Choose one

Year: -- Choose one

Is this job fulltime?

j Yes
k
l
m
n
j No
k
l
m
n
Employer type
Which of the following categories best describes this individual's employer for this job?
(choose one or more)

c A private, for-profit company, business, or individual paying wages, salary, or
d
e
f
g
commissions
c A private not-for-profit, tax-exempt, or charitable organization
d
e
f
g
c Self-employment in own not incorporated business, professional practice, or farm
d
e
f
g

c Self-employment in own incorporated business, professional practice, or farm
d
e
f
g
c Local government (e.g., city, county)
d
e
f
g
c State government
d
e
f
g
c U.S. military service, active duty, or commissioned corps (e.g., USPHS, NOAA)
d
e
f
g

c U.S. Government as a civilian employee
d
e
f
g
c Other (please specify):
d
e
f
g
Employment sector
Regarding this individual's employer's main business (i.e., what the employer makes or
does), please indicate the single category that best fits the employer's main business. If the
employer has more than one type of business, please answer for the type of work primarily
performed at the location where this individual works.
-- Choose one
If "Research" or "Other" is selected, please specify:

Position/job title (broad category)
--Choose one
If "Other" is selected, please specify:

Position/job title
-- Choose one --

Is this job STEM related?
--Choose one

Work in Education
Is the employer an educational institution?

j Yes
k
l
m
n
j No
k
l
m
n
If yes, answer the following questions:
Type of educational institution
--Choose one
If "Other" is selected, please specify:

Faculty rank
--Choose one
If "Other" is selected, please specify:

Tenure status
--Choose one

Save

Cancel

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LOUIS STOKES ALLIANCES FOR MINORITY PARTICIPATION

Bridge to the Doctorate Program

Annual Survey

July 1, 2006–June 30, 2007

ZQRC Test University YX | Logout

Welcome
1. Respondent Contact Info

Main Menu » Peer Students » Student Menu » Baseline Data

2. Student Data
3. Final Submission
Help & Instructions

Baseline Data
STUDENT: THOMAS WILLIAMS

Print My Data

Student's name (First, MI, Last)

Download My Data

Thomas

Williams

Add Comments/Feedback
Contact Us

Bachelor's degree-awarding institution

Survey last modified
March 29, 2007

Social Security number

OMB# 3145-0136
LSAMP Program
< Insert New Date >

Student ID at the Institution

Gender

j Female n
k
l
m
i Male n
j
k
l
m
n
j Not reported
k
l
m
Ethnicity
Not Hispanic or Latino

Race (choose one or more)

c American Indian or Alaska Native
d
e
f
g

c Asian
d
e
f
g
c Black or African American
d
e
f
g
c Native Hawaiian or Other Pacific Islander
d
e
f
g
b White
c
d
e
f
g

c Not reported
d
e
f
g
Disability (choose one or more)

c Hearing impairment
d
e
f
g
c Mobility or orthopedic impairment
d
e
f
g
c Visual impairment
d
e
f
g

c Other (please specify):
d
e
f
g
c None
d
e
f
g

c Not reported
d
e
f
g
Citizenship
U.S. Citizen/U.S. National
If "Other" is selected, please specify:

Date of bachelor's degree
Month: June

Year: 2004

Undergraduate major (choose one or more)

c Agricultural Science
d
e
f
g
c Chemistry
d
e
f
g

b Computer Science
c
d
e
f
g
c Engineering
d
e
f
g
c Environmental Science
d
e
f
g
c Geosciences
d
e
f
g
c Life/Biological Sciences
d
e
f
g

c Mathematics
d
e
f
g
c Physics/Astronomy
d
e
f
g
c Other (please specify):
d
e
f
g
Undergraduate GPA
3.8

Undergraduate GPA Scale

i 4 Point scale
j
k
l
m
n

j 5 Point scale
k
l
m
n

Research experience during the undergraduate program?

j Yes
k
l
m
n
i No
j
k
l
m
n
GRE scores
Verbal:
Quantitative:
Analytical:

Date entered the STEM graduate program
Month: -- Choose one

Year: 2004

Date entered the current graduate program
Month: April

Year: 2004

Graduate work prior to entering the current graduate program
Did this student complete any graduate work before entering the current

graduate program?

i Yes
j
k
l
m
n
j No
k
l
m
n
If yes, please provide the following data:
Broad field area
Computer and Information Sciences

If "Other" is selected, please specify:

Field
Computer/systems

Degree
No specific degree or certificate

If "Other" is selected, please specify:

Date degree awarded
Month: -- Choose one

Year: -- Choose one

If no prior graduate degrees please provide the number of graduate credits
completed prior to entering the current graduate program 36

Teaching assistantship awarded prior to entering the current graduate
program?

j Yes
k
l
m
n
i No
j
k
l
m
n
j Not applicable
k
l
m
n
Research assistantship awarded prior to entering the current graduate
program?

j Yes
k
l
m
n

i No
j
k
l
m
n
j Not applicable
k
l
m
n

Save

Cancel

Skip navigation
LOUIS STOKES ALLIANCES FOR MINORITY PARTICIPATION

Bridge to the Doctorate Program

Annual Survey

July 1, 2006–June 30, 2007

ZQRC Test University YX | Logout

Welcome
1. Respondent Contact Info

Main Menu » Peer Students » Student Menu » Annual Data

2. Student Data
3. Final Submission
Help & Instructions
Print My Data

Annual Data
THOMAS WILLIAMS

Graduate program

Download My Data
Add Comments/Feedback
Contact Us

Intended broad major area
-- Choose one --

Survey last modified
March 29, 2007

If "Other" is selected, please specify:

OMB# 3145-0136
LSAMP Program
< Insert New Date >

Intended major
-- Choose one

Intended degree (choose one or more)

c No specific degree or certificate
d
e
f
g
c Postbaccalaureate certificate
d
e
f
g
c Master's (including M.B.A.)
d
e
f
g

c Post-Master's certificate
d
e
f
g
c Doctorate (Ph.D., D.S.C., D.Sc., Ed.D.)
d
e
f
g
c Other professional degree (J.D., L.L.B., Th.D., M.D, D.D.S., etc.)
d
e
f
g
c Other (please specify):
d
e
f
g
Number of graduate course credits completed during the current reporting
period (July 1, 2006–June 30, 2007)

Teaching assistantship awarded during the current reporting period (July 1,
2006–June 30, 2007)

j Yes
k
l
m
n

j No
k
l
m
n
j Not applicable
k
l
m
n
Research assistantship awarded during the current reporting period (July
1, 2006–June 30, 2007)

j Yes
k
l
m
n
j No
k
l
m
n
j Not applicable
k
l
m
n
Year entered Ph.D. track (please use the definition below)
(completed 2 years of graduate coursework, equivalent to M.A. or M.S. and entered third
year of graduate coursework, i.e., post M.S. and into Ph.D. track)
-- Choose one

Thesis proposal - date approved (thesis not required)
Month: -- Choose one

Year: -- Choose one

Master's degree - date awarded
Month: -- Choose one

Year: -- Choose one

Ph.D. qualifying examinations - date passed
Month: -- Choose one

Year: -- Choose one

Ph.D. candidacy - date attained
Month: -- Choose one

Year: -- Choose one

Dissertation defense - date passed
Month: -- Choose one

Year: -- Choose one

Doctoral dissertation - date approved
Month: -- Choose one

Year: -- Choose one

Doctoral degree - date awarded
Month: -- Choose one

Year: -- Choose one

Doctoral dissertation abstract

Did the student leave the program or drop out during the current reporting
period (July 1, 2006–June 30, 2007)?

j Yes
k
l
m
n

j No
k
l
m
n
Date left or dropped out
Month: -- Choose one

Year: -- Choose one

If he or she left, was it to continue the Ph.D. elsewhere?

j Yes
k
l
m
n

j No
k
l
m
n
j Do not know
k
l
m
n
If yes, please provide the following information:
Transfer date Month: -- Choose one

Year: -- Choose one

Institution name

Permanent Contact Information
Please provide the permanent contact information for this student.

Student's personal e-mail address

(other than his or her current school address, if available)

Address

City

State
(If address is not in the United States, select "Non-U.S.")
Choose one

ZIP Code

Country

Phone (xxx-xxx-xxxx)

Ext.

Other Contact Information
Name and address (U.S. postal and e-mail) of a person likely to know how to reach this
student after he or she graduates.

Name

Relationship to this student

E-mail address

Address

City

State
(If address is not in the United States, select "Non-U.S.")
Choose one

ZIP Code

Country

Phone (xxx-xxx-xxxx)

Save

Cancel

Ext.

Skip navigation
LOUIS STOKES ALLIANCES FOR MINORITY PARTICIPATION

Bridge to the Doctorate Program

Annual Survey

July 1, 2006–June 30, 2007

ZQRC Test University YX | Logout

Welcome
1. Respondent Contact Info

Main Menu » Peer Students » Student Menu » Followup Data

2. Student Data
3. Final Submission
Help & Instructions
Print My Data
Download My Data
Add Comments/Feedback
Contact Us

Followup Data
THOMAS WILLIAMS

Postdoctorate appointment
Has the individual received a postdoctorate appointment?

j Yes
k
l
m
n
j No
k
l
m
n

Survey last modified
March 29, 2007

If yes, please complete the following items:
Date

OMB# 3145-0136
LSAMP Program
< Insert New Date >

Month: -- Choose one

Year: -- Choose one

Institution
Department
Field

Current Employment
Is the individual currently employed?

j Yes
k
l
m
n
j No
k
l
m
n
If yes, please answer the following questions about this individual's main
job:
When did the individual begin this job?
Month: -- Choose one

Year: -- Choose one

Is this job fulltime?

j Yes
k
l
m
n
j No
k
l
m
n
Employer type
Which of the following categories best describes this individual's employer for this job?
(choose one or more)

c A private, for-profit company, business, or individual paying wages, salary, or
d
e
f
g
commissions
c A private not-for-profit, tax-exempt, or charitable organization
d
e
f
g
c Self-employment in own not incorporated business, professional practice, or farm
d
e
f
g

c Self-employment in own incorporated business, professional practice, or farm
d
e
f
g
c Local government (e.g., city, county)
d
e
f
g
c State government
d
e
f
g
c U.S. military service, active duty, or commissioned corps (e.g., USPHS, NOAA)
d
e
f
g

c U.S. Government as a civilian employee
d
e
f
g
c Other (please specify):
d
e
f
g
Employment sector
Regarding this individual's employer's main business (i.e., what the employer makes or
does), please indicate the single category that best fits the employer's main business. If the
employer has more than one type of business, please answer for the type of work primarily
performed at the location where this individual works.
-- Choose one
If "Research" or "Other" is selected, please specify:

Position/job title (broad category)
--Choose one
If "Other" is selected, please specify:

Position/job title
-- Choose one --

Is this job STEM related?
--Choose one

Work in Education
Is the employer an educational institution?

j Yes
k
l
m
n
j No
k
l
m
n
If yes, answer the following questions:
Type of educational institution
--Choose one
If "Other" is selected, please specify:

Faculty rank
--Choose one
If "Other" is selected, please specify:

Tenure status
--Choose one

Save

Cancel