Form 9 CCSEP Alumni Tracking

COMMUNITY COLLEGE SUMMER ENRICHMENT PROGRAM (CCSEP) - ALUMNI
UPDATE
OMB Clearance Number: 0925-0299
Expiration Date: 30-Jun-2022

First Name (Given Name):*

Last Name (Family Name):*

Email Address (one that you check regularly):*

What Year(s) did you participate in CCSEP?

COMMUNITY COLLEGE INFORMATION
Community College ‑ Name:

Community College ‑ Academic Major:

Community College ‑ Degree (anticipated or awarded):

Community College ‑ Graduation Date (anticipted or awarded):

UNDERGRADUATE UNIVERSITY INFORMATION
Undergraduate University ‑ Name:

Undergraduate University ‑ Academic Major:

Undergraduate University ‑ Degree (anticipated or awarded):

Undergraduate University ‑ Graduation Date (anticipated or awarded):

GRADUATE UNIVERSITY INFORMATION

Graduate University ‑ Name:

Graduate University ‑ Academic Major

Graduate University ‑ Degree (anticipated or awarded):

Graduate University ‑ Graduation Date (anticipated or awarded):

RESEARCH EXPERIENCE INFORMATION
Have you received any additional research experience after your CCSEP internship ended?

Have you participated in any other OITE programs?

Which OITE programs did you participate?

Do you have any peer‑reviewed publication(s)?

Provide the citation in APA format:

CAREER DEVELOPMENT
What is your current professional status?

If enrolled in a degree program, what is the name of the program?

If enrolled in a degree program, what degree are you pursuing?

If employed, what is the name of your employer?

If employed, what is your job title?

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Collection of this information is authorized by The Public Health Service Act, Section 410 (42 USC 285). Rights
of participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties
for not participating or withdrawing from the study at any time. The information collected in this study will
be kept private to the extent provided by law. Names and other identifiers will not appear in any report of the
study. Information provided will be combined for all participants and reported as summaries.

6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0299). Do not return the
completed form to this address.