2 2014 AC Exit Form

National Service Trust Exit Form

This form will end the term of an AmeriCorps member in the National Service Trust and report on the eligibility of the member for a Segal Education Award. It will also provide the Corporation for National and Community Service (CNCS) with evaluation exit data. This form may be filled out on paper or electronically.

PART 1

Member: Please Complete and Sign

1. Name

Last

First

MI

2. Social Security Number

3. Mailing Address (Where the Segal Education Award should be sent, if mailed)

Number and Street

City

State

Zip Code

Email Address

Home Phone

Business Phone

Ext

4. For VISTA Volunteers only: I would like to

Complete my service as scheduled

Reenroll for another year

Extend my service for less than a year

Terminate my service early

CNCS gathers information about education and disability status to ensure opportunities to serve are provided for people of all conditions. This information will be held confidentially, and will solely be used for data analysis to assist us in ensuring we serve all Americans equally. The information you provide will not be used in any way to determine or affect any federal benefit. Under the Rehabilitation Act (Act) information on your disability status can only be used in connection with non-discrimination and affirmative action obligations. The information will be kept confidential in accordance with the Act’s provisions and the information will be used only in accordance with the Act. Your responses are required in order to successfully verify your service.

5. Disability status.

The next questions address disability and serious health conditions. Your responses will ensure that our outreach and recruitment policies are reaching a wide range of individuals with physical or mental conditions. Consider your answers without the use of medication and aids (except eyeglasses) or the help of another person.

Do you have one of the following? Check all that apply to you:

Deaf or serious difficulty hearing

Blind or serious difficulty seeing even when wearing glasses

Missing an arm, leg, hand, or foot

Paralysis, partial or complete (any cause)

Significant disfigurement, for example, severe disfigurements caused by burns, wounds, accidents, or congenital disorders

Significant mobility impairment, for example, use of a wheelchair, scooter, walker, or use of a leg brace to walk

Significant psychiatric disorder, for example, bipolar disorder, schizophrenia, PTSD, or major depression

Intellectual disability (formerly described as mental retardation)

Developmental disability, for example, cerebral palsy or autism spectrum disorder

Traumatic brain injury

Dwarfism

Epilepsy or other seizure disorder

Other disability or serious health condition, for example, diabetes, cancer, cardiovascular disease, anxiety disorder, or HIV infection; a learning disability, a speech impairment, or a hearing impairment.

If you did not select one of the options above, please indicate why:

I have a disability or serious health condition but do not wish to specify my condition

I do not wish to answer questions regarding disability/serious health conditions.

None of the conditions listed above apply to me.

If you selected “Other disability or serious health condition”, please select any of the conditions listed below that apply to you. Please check all that apply.

Alcoholism

Cancer

Cardiovascular or heart disease

Crohn’s disease, irritable bowel syndrome, or other gastrointestinal impairment

Depression, anxiety disorder, or other psychological disorder

Diabetes or other metabolic disease

History of drug addiction (but not currently using illegal drugs)

HIV infection/AIDS or other immune disorder

Kidney dysfunction, for example, requiring dialysis

Learning disabilities or ADHD

Liver disease, for example, hepatitis or cirrhosis

Lupus, fibromyalgia, rheumatoid arthritis, or other autoimmune disorder

Morbid obesity

Nervous system disorder, for example, migraine headaches, Parkinson’s disease, or multiple sclerosis

Non-paralytic orthopedic impairments, for example, chronic pain, stiffness, weakness in bones or joints, or some

loss of ability to use parts of the body

Orthopedic impairments or osteo-arthritis

Pulmonary or respiratory impairment, for example, asthma, chronic bronchitis, or TB

Sickle cell anemia, hemophilia, or other blood disease

Speech impairment

Spinal abnormalities, for example, spina bifida or scoliosis

Thyroid dysfunction or other endocrine disorder

Other. Please identify the disability or health condition:

6. Do you receive Social Security disability benefits, such as Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI)?

Yes No Prefer not to respond

7. School Status

Has your highest level of education changed since you enrolled? Yes No

If yes, please answer the following questions:

What is your highest level of education?

Less than high school

High school diploma/GED

Technical school/apprenticeship/vocational

Some college

Associates degree (AA)

College graduate

Graduate degree (e.g. MA, PhD, MD, JD)

If you have some college:

Choose the most recent school you attended

If school is not listed, provide name here

Type of degree, diploma, or certificate

If you have an Associate’s degree:

Choose the school from which you received your most recent Associate’s degree

If school is not listed, provide name here

Type of degree, diploma, or certificate

If you have a Bachelor’s degree:

Choose the school from which you received your most recent Bachelor’s degree

If school is not listed, provide name here

Type of degree, diploma, or certificate

If you have a graduate degree:

Choose the school from which you received your most recent graduate degree

If school is not listed, provide name here

Type of degree, diploma, or certificate

8. Privacy Act Information Release

Yes, I give the Corporation for National and Community Service permission to release the following information about me to an AmeriCorps Alumni Association (check all that apply):

Name

Address

Email

Telephone Number

0 No, I do not give the Corporation for National and Community Service permission to release my information to an AmeriCorps Alumni Association.

9. Post Service Opportunities:

The Corporation for National and Community Service would like to provide you with information and resources to help you stay engaged in service and connect with educational, professional, and alumni opportunities. Please check all that apply.

I am interested in connecting with other AmeriCorps alumni.

I am interested in learning more about educational opportunities and how to use my Segal Education Award.

I am interested in professional development trainings, resume-writing resources, and career opportunities.

0 Corps

I am not interested in this information and resources.

Certification of Service:

I certify that the time I reported to my program as program service hours is true and correct and did not include any service activities prohibited by law, regulation, or grant provisions. I agree, by signing this form, to provide, if asked, documentation to verify the accuracy of the information I have provided in this form.

I understand that a knowing and willful false statement on this form can be punished by one or more of the following: a fine or imprisonment (or both) under Section 1001 of Title 18, USC; exclusion from participation in Federal programs; forfeiture of benefits I may receive as a result of participation in this program; or other actions authorized by the Civil Fraud Remedies Act, 31 USC 3801-3812.

Member’s Signature: Date:

Privacy Statement—In compliance with the Privacy Act of 1974, the following information is provided: The evaluative information will help CNCS improve its programming and services to members. Information may be shared with other agencies, such as the Social Security Administration, through computer matching agreements for the purpose of verifying identity information provided by you in this document. The Internal Revenue Service has determined that the Segal Education Award is taxable in the year it is used. Your Social Security Number (SSN) is solicited under the authority of the Internal revenue Code (26 U.S.C. 6011(b) and 6109) for use as a taxpayer identification number. Failure to disclose your actual SSN or any other information may result in a denial of your receiving a Segal Education Award or it may delay the processing of your education award. All information provided will be treated confidentially and will not be disclosed except for an official need to know.

Public reporting burden—Estimated time to complete this form, including time for reviewing instructions, gathering, and providing the information needed to

complete the form is three minutes for the Member section and four minutes for the Certifying Official section. Send comments regarding this burden or the content

of this form to: Corporation for National and Community Service, National Service Trust, 1201 New York Avenue, NW, Washington, DC 20525. CNCS informs the potential persons who are to respond to this collection of information that such persons are not required to respond to the collection of information unless it displays a currently valid OMB control number on this page of the form (see 5CFR 1320.5(b)(2)(1)).

OMB No.: 3045-0006

Exit information should be electronically submitted to CNCS within 30 days of completion of service.

PART 2

Certifying Official: Please Complete and Sign

This section must be signed by an authorized certifying official. The program must designate certifying officials electronically to the

Corporation for National and Community Service.

1. Name of Program or AmeriCorps*NCCC Campus

2. Operating Site I.D. Number

3. Hours of Service Performed

(not applicable for VISTA) Hours

4. Date of Completion of Term of Service

Month Day Year

5. Type of Enrollment

(Mark only one.)

Full-time (1700 hours per year, or 365 days per year for VISTA)

VISTA Summer Associate (10-12 weeks)

Half-time (900 hours in no more than 2 years)

Half-time (900 hours in no more than 1 year)

Reduced half-time 675 hours

Quarter time 450 hours

Minimum time/Summer 300 hours

AmeriCorps Affiliate 100 hours

6. Segal Education Award Status:

Indicate whether or not the Member is eligible for a Segal Education Award. Please be sure to follow CNCS’s regulations in making this selection. If the Member is going to serve another term under the National Service Trust, a new National Service Enrollment Form

must be completed.

Eligible for entire Segal Education Award (member successfully completed service)

Eligible for partial Segal Education Award (member did not fully complete service for compelling personal reasons)

Not eligible for Segal Education Award (member did not fully complete service requirements)

Not eligible for Segal Education Award (member chose alternative benefit)

Not eligible for Segal Education Award (member dismissed for misconduct)

Not eligible for Segal Education Award.

Other (Specify):

7. Did the member perform satisfactorily (complete all assignments, tasks, and projects)?

Note, responding “No” may restrict future membership opportunities for this individual Yes

No

8. Certification of Service

I certify that to the best of my knowledge and belief, the time the above-listed member reported as AmeriCorps, Silver Scholar, or Serve America Fellow program service hours did not include any service activities prohibited by law, regulation, or grant provision;

That the member performed satisfactorily (completed all assignments, tasks, and projects); and that the hours of service performed indicated on this form for this service member are true and accurate.

I understand that a knowing and willful false statement on this form can be punished by a fine or imprisonment or both under Section 1001of Title 18, U.S.C. or other actions authorized by the Civil Fraud Remedies Act, 31 USC 3801-3812.

Signature of Certifying Official: Date:

Name of Certifying Official (Please Print):