Teacher Recommendation

Attachment C OMB No. 0920-1185

Expiration Date: 03/31/2026

National Center for Health Statistics

Data Detectives Summer Camp

From the Office of Management and Budget (OMB No. 0920-1185, Expiration Date: 03/31/2026):

NOTICE - Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the 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 currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC/ATSDR Information Collection Review Office; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-1185).

Assurance of Confidentiality - We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2018 (CIPSEA Pub. L. No. 115-435, 132 Stat. 5529 § 302). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. In addition to the above cited laws, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 and 151 note) which protects Federal information systems from cybersecurity risks by screening their networks.

Teacher Recommendation Form

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.

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

Signed: _______________________________________ Date: _______/________/________

(Signature of camp applicant) (Month) (Day) (Year)

Recommender

This section is to be completed by the student’s math teacher:

Our camp is a summer program for all students who are interested in math and statistics and will be entering grades 6 or 7. Recommendations may not be submitted by family members or relatives.

After completing the form, place it in an envelope, seal it, and write your name across the sealed flap. Please send the sealed envelope by postal mail no later than. We are unable to accept any forms sent via email this year.

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 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 needs 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)

Feel free to attach a letter with this form to provide additional information about the applicant.

Send completed form, including any attachment(s), via your school email address from the school you teach. Forms submitted via personal email accounts will not be accepted.

If you would prefer to send it via postal mail, place the completed form, including any attachment(s), in a sealed envelope and sign across the seal. Send to the address below. POSTMARK DEADLINE is TBD.

Ryne Paulose

NCHS/CDC

3311 Toledo Rd

Hyattsville, MD 20782

If you have any questions, please contact us at [email protected].

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