0920-0729 Att D Teacher Form

Attachment D OMB No. 0920-0729 Exp. Date 05/31/2017

National Center for Health Statistics

Data Detectives Summer Camp 2016

Notice-Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to: CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0234).

Assurance of confidentiality-All information which would permit identification of an individual, a practice, or an establishment will be held confidential; will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls; and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Teacher Recommendation Form

To the camp applicant: Please type or neatly print the requested information below. Then give this form to a math teacher who knows you well enough to assess your ability to participate in the Data Detectives Summer Camp.

Camp Applicant: ________________________________________________________________

Last Name First Name Middle Initial

“I hereby waive any rights I may have to examine this confidential information”

Signed: _________________________________________ Date: _______/________/________

(Signature of student applicant) (month) (day) (year)

To be completed by Recommender:

NOTE: Our camp is a summer program for all students who are interested in math and statistics and will be entering grades 6^th through 8^th. Recommendations may not be submitted by family members or relatives. When you finish, put this form into an envelope, seal it, and write your name across the sealed flap. Please mail the sealed envelope no later than May XX, 2016.

1. How long (in what capacity) have you known the applicant and in what context?

2. Please rate your impression of the applicant for the following statements:

1 = Below Average 2 = Average 3 = Above Average 4 = Excellent N/A = Unable to Judge

1. Academic achievement ____

2. Interest in math ____

3. Level of maturity ____

4. Willingness to accept direction and/or supervision ____

5. Sensitivity to needs and feelings of others ____

6. Ability to get along with others ____

7. Commitment to his or her education ____

8. Behavior on a typical day ____

3. What do you consider to be the applicant’s relative weakness or area that leaves room for improvement as a potential participant in this summer program?

4. What do you consider to be the applicant’s relative strength as a potential participant in this program?

5. Summary of Evaluation

_____I do not recommend this applicant for admission.

_____I think that the applicant’s qualifications are marginal, but if admitted, the

applicant would greatly benefit from participating in the program.

_____I do recommend this applicant for admission and without reservation.

_______________________________________ ____________________________________

Name Title

______________________________________________________________________________

School Name

____________________________________ _______________________________________

Phone Number Email address

Signed: ____________________________________________ Date: _______ /______ /_______

(Signature of teacher) (month) (day) (year)

Note: Please feel free to attach a letter with this form to provide additional information about the applicant.

Place completed recommendation form in a sealed envelope and sign across the seal. Mail it directly to:

Ryne Paulose

NCHS/CDC

Hyattsville, MD 20782

POSTMARK DEADLINE: Month/Day/Year

[email protected]

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