Voluntary Student Engagement Form

U .S. Department of Education

Office of Communications and Outreach

Voluntary Student Engagement Form

Please assist our department by providing us with a narrative relating to your event with <insert senior official> today. Completing this form is voluntary, and your responses will be cataloged by location, subject and/or educational priority.

The information in the first section “Student Contact Information” may be used for youth engagement purposes (for example, to invite you to potential follow up meetings/events around an education priority issue and/or to subscribe you to the ED Youth Voices Newsletter). The information in the second section, “Student Narrative Information” may be used in the future for communications development (for example, to write blogs, speeches, presentations and newsletters) along with your first name and city, or with your consent, your full name.

1. Student Contact Information – This information is intended for youth engagement purposes. The information will not be shared publicly or with external stakeholders.

Student Name:

Email Address:

Phone Number:

Address Line 1:

Address Line 2:

City, State + Zip:

School/Organization

Contact Person:

Contact’s Position:

⃝ Check this box if we may follow up with you to further engage on this and other education issues

⃝ Check this box if you would like a subscription to the ED Youth Voices newsletter, your email address will be added to a secure email distribution system.

2. Student Narrative Information – This information is intended for message development purposes. By responding to the questions below, you are providing consent for the responses to be used in the creation of external facing content (such as blogs, speeches, presentations and newsletters) that will be shared publicly along with your first name, school/organization and city.

During the event with <insert senior official> you shared your story and it left an impression on him/her. In one or two brief paragraphs in the space below, please elaborate on your story. For example, if you had an opportunity to talk to Secretary Duncan about yourself, what would you want him to know? Are there any lessons that others can learn from you or your experience? Tell us about them. Please reasonably limit your responses to a paragraph or two.

What are your future aspirations?

What people and/or experiences have helped you achieve these aspirations? Have you experienced any roadblocks to achieving your goals? If so, what are they?

For Office Use:
ED Priority: Choose an item.	ED Contact: Click here to enter text.	Event Name: Click here to enter text.	Event Date: Click here to enter a date.

PRA Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number.  The valid OMB control number for this information collection is 1800-0011.  Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  The obligation to respond to this collection is voluntary.  If you have comments or concerns regarding the status of your individual submission of this survey, please contact the Office of Communications and Outreach, 400 Maryland Avenue, SW, LBJ, 7W101, Washington, DC 20202-3500 directly. [Note: Please do not return the completed survey to this address.]