Teacher Recommendation

Attachment D OMB No. 0920-1185 Exp. Date 05312020

National Center for Health Statistics

Data Detectives Summer Camp

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 USC 242m(d)).

Teacher Recommendation Form

To the 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.

Camp Applicant: ________________________________________________________________

Last Name First Name Middle Initial

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

Signed: _________________________________________ Date: _______/________/________

(Signature of student applicant) (month) (day) (year)

To be completed by Recommender:

NOTE: 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.

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 and/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 leaves room for 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)

Note: Please feel free to attach a letter with this form to provide additional information about the applicant.

You have 2 options for sending the completed form back to us:

1. Place completed form, including any attachment(s), in a sealed envelope and sign across the seal. Mail it directly to the address below. POSTMARK DEADLINE is Month/Day/Year

Ryne Paulose

NCHS/CDC

Hyattsville, MD 20782

2. PDF the completed form, including any attachment(s), and email it directly from your school email account to datadetectives@cdc.gov. EMAIL RECIEPT DEADLINE is Month/Day/Year

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