Form NIFA-2010 Fellowships/Scholarships Entry/Annual Update/Exit Form

UNITED STATES DEPARTMENT OF AGRICULTURE
COOPERATIVE STATE RESEARCH, EDUCATION, AND EXTENSION SERVICE

OMB Approved 0524-0039

Fellowships/Scholarships Entry/Exit Form
APPOINTMENT INFORMATION
Institution:

Grant Number:

Project Director:

Telephone:

Fellow/Scholar Name and
Permanent Address:

Sex:

FAX:

9 Male
9 Female

Citizenship:
USA or permanent
resident
Other (specify)

9

9
Degree Sought:

9 AS/AA

9 BS/BA

Date:

Race: (Check all that apply)

Ethnicity:

9 American Indian or Alaskan Native
9 Black or African American
9 Asian
9 Native Hawaiian or Other Pacific Islander
9 White

9 Hispanic or Latino
9 Not Hispanic or Latino

9 DVM

Declared Major:
Date Enrolled: (mm/dd/yyyy)

E-mail:

9 Master’s

Disability Status:
Yes
No

9

9

9 Doctorate
✔

Minor:

Official Stipend Dates:
Began (mm/dd/yyyy)
Permanently Terminated (mm/dd/yyyy):

SCHOLAR

FELLOW

Previous Academic Background

Previous Academic Background

High School

Baccalaureate Degree

Institution Name:

Institution Name:

Year Graduated:

Major:
Associate Degree

Institution Name:

Minor:

Number of Credits (Indicate Semester or Quarter System):
Year Graduated:

Major:

Minor:

Overall GPA (4.0 System):

Number of Credits (Indicate Semester or Quarter System):
Year Graduated:

Master’s Degree
Institution Name:

Overall GPA (4.0 system):

Major:

Baccalaureate Degree

Minor:

Number of Credits (Indicate Semester or Quarter System):

Institution Name: University of Maryland

Year Graduated:

Major:

Overall GPA (4.0 System):

Minor:

Number of Credits (Indicate Semester or Quarter System):

Master’s Thesis Title:

Year Graduated:

DVM Degree

Overall GPA (4.0 system):

Institution Name:

Transfer or Other Credits
Institution Name:
Major:

Major:

Minor:

Number of Credits (Indicate Semester or Quarter System):
Minor:

Number of Credits (Indicate Semester or Quarter System):
College Admission Scores (complete all that apply):

Year Graduated:
Overall GPA (4.0 System):
Graduate School Admission Scores:

ACT Composite:

GRE

Other

SAT Verbal:
SAT Math:

Verbal

Other Score:

Analytical

Other Score:

Quantitative

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays
a valid OMB control number. The valid OMB control number for this information collection is 0524-0039. The time required to complete this information collection is estimated to
average 3.00 hours 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.

Form CSREES-2010

Page 1

UNITED STATES DEPARTMENT OF AGRICULTURE
COOPERATIVE STATE RESEARCH, EDUCATION, AND EXTENSION SERVICE

OMB Approved 0524-0039

Fellowships/Scholarships Entry/Exit Form
ANNUAL UPDATE
Grant No:

Scholar/Fellow Name:
Degree Sought:

9 AS/AA

9 BS/BA

9 DVM

Academic Level:

9 Freshman 9 Sophomore
9 Junior, Senior 9 Graduate Student

9 Master’s

Date:

9 Doctorate
FELLOWS

SCHOLARS

GPA of Scholar while on USDA Stipend Support:

Current GPA of Fellow while on USDA Stipend:
Graduate Major:
Overall:
Graduate Major:

Overall:
Major:
Minor:
Other:

Specialization:
Collateral:
Thesis/Dissertation Topic:

Institutional Financial Support Provided to Scholar
in Addition to USDA Stipend
Amount
Stipend
Scholarship
Tuition Waiver

Period Covered

Additional Institution Financial Support Provided:

9 Teaching Assistantship
9 Research Assistantship
9 Grant to Support Research Costs 9 Scholarship
9 Other (Explain):

Housing Waiver
Loan

Comments:

Work Study
Other Support
Explain Other Support:

Academic Accomplishments (Fellows should include publications based on graduate research):

Honors/Awards received while in the program (Text):

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays
a valid OMB control number. The valid OMB control number for this information collection is 0524-0039. The time required to complete this information collection is estimated to
average 3.00 hours 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.

Form CSREES-2010

Page 2

UNITED STATES DEPARTMENT OF AGRICULTURE
COOPERATIVE STATE RESEARCH, EDUCATION, AND EXTENSION SERVICE

OMB Approved 0524-0039

Fellowships/Scholarship Entry/Exit Form
EXIT INFORMATION
SCHOLAR/FELLOW

Current Date:

Grant Number:

Name:

Permanently Terminated: (mm/dd/yyyy)

Address:

Reason Fellowship/Scholarship Support Permanently Terminated:
1.

9 Degree Granted
Final GPA:

2.
3.

-- Date:

Major

Overall

9 Stipend Eligibility Expired: -- Reason:
9 Accepted Alternative Support -Amount:

Source:

9 Transferred to Another Program/Changed Major to:
5. 9 Transferred to Another Institution --

4.
E-mail:
Phone Number:

Name of Other Institution:

9 Withdrew From School
7. 9 Dismissed for: ______ Disciplinary Reasons ______ Academic Reasons
8. 9 Other -- Explain:

6.

Future Plans (complete all that apply):

9 Continue Education After Completion of Current Degree Program by Pursuing the Following:
9 Doctorate Degree
9 Post-Doctorate Study
9 Research Associateship/Traineeship
9 Employment Interviews:
Potential Employer

Position Discussed

Estimated Annual Salary

$
$

9 Pursue Employment with

Job Offer

9 No 9 Yes
9 No 9 Yes
9 No 9 Yes

$

Accepted

Declined

Accepted

Declined

Accepted

Declined

(type of business/organization)

To be completed by Project Director - Describe the Value and Impact of the Program on Your Campus:

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays
a valid OMB control number. The valid OMB control number for this information collection is 0524-0039. The time required to complete this information collection is estimated to
average 3.00 hours 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.

Form CSREES-2010

Page 3