Instructions for Javits Student Report Form

ATTACHMENT E

Form Approved

OMB No. 1840-0781

Expiration Date: XX/XX/XXXX

UNITED STATES DEPARTMENT OF EDUCATION

OFFICE OF POSTSECONDARY EDUCATION

JACOB K. JAVITS FELLOWSHIP PROGRAM

(Title VII, Part A, Higher Education Act of 1965, as amended)

INSTRUCTIONS FOR ANNUAL STUDENT ACTIVITIES REPORT

1. Please provide your first and last name in the space provided.

2. Please provide your current and permanent mailing addresses in the space provided.

3. Please provide your e-mail address in the space provided.

4. Please select one of the options shown below to denote your race in the space provided.

Race: ______ American Indian or Alaska Native

______ Asian

______ Black or African American

______ Native Hawaiian or Other Pacific Islander

______ White

5. Please select one of the options shown below to denote your ethnicity in the space provided.

Ethnicity: ______ Hispanic or Latino

______ Not Hispanic or Latino

6. Please select one of the options shown below to denote your gender in the space provided.

Gender: ______ Female ______ Male

7. Please list the name of the institution administering the Javits grant award

and your fellowship in the space provided.

8. Please indicate the year and the term you entered your graduate program in the space provided.

9. Please select one of the options shown below to denote the graduate degree program that you are pursuing in the space provided.

Degree Program: ______ 2-year MFA (Master of Fine Arts) degree

______ 3-year MFA (Master of Fine Arts) degree

______ PhD

10. In the space provided, please indicate your current academic status by

selecting the applicable status for either the MFA Degree or PhD Degree

classification areas.

MFA: ______Completed 1st Year Coursework
______Completed 2nd Year Coursework
______Completed Thesis/Portfolio/Performance or

recital

PhD: ______Enrolled but not yet advanced to PhD Candidacy
______Passed preliminary exams and advanced to PhD

11. Please provide the month and year of your expected graduation in the space

provided.

12. Please indicate the total number of years you received Javits funding in the space provided.

13. In the space provided, please describe the research activities, teaching experience or other activities in which you have participated during the past year.

14. In the space provided, please provide specific examples of conferences and you have attended and publications that you have presented during the past year.

15. In the space provided, if you were engaged in a part-time work experience during the past year, please indicate the type of employment.

Please discuss briefly your part-time work experience in the additional space provided.

16. In the space provided, if you took an Interruption of Study, please indicate the purpose of the Interruption and discuss the activities in which you participated.

17. In the space provided, please discuss your current goals and employment plans upon earning your degree.

18. Please indicate whether or not you have submitted the FAFSA for the [insert year]-[insert year] academic year in the space provided.

19. In the space provided, please explain the impact that receiving a Javits fellowship had upon your decision to enter graduate school.

20. In the space provided, please explain the impact the Javits fellowship had upon your choice of academic area at your institution.

21. In the space provided, please indicate whether or not you had other

fellowship offers at the time you were awarded the Javits fellowship.

If “Yes,” please specify the other offers you received in the additional space

provided.

If “Yes,” please explain what prompted your decision to accept the Javits

fellowship over your other fellowship offers in the space provided.