Graduate School Doctoral Dissertation Completion Grant Nomination Form

7/1/2016-12/31/2016

To nominate a graduate student for a Doctoral Dissertation Completion Grant, please complete this form and attach the followingsupporting documentation:

-A brief (one page) summary of the project, including research question(s), data or texts, and method.

-A justification of the need for the award from the student’s committee chair. This should include the student’s 1) research progress to date, 2) the type of obstacles or difficulties beingencountered that are hindering the completion of the dissertation,3) how these difficulties haveprevented thenominee from making satisfactory progress on the dissertation, and 4) the extent towhich the student has potential to complete the dissertation within the grant period. (It is important to address not only financial obstacles, but other obstacles as well. Nominations that identify obstacles beyond those that are financial will receive highest priority.)

-Statementof interest and justification for participation in this program from the nominee.

-A one-page proposal outlining a plan (including a time-line) for completion of the dissertation.

-A CV for the nominee.

This form and supporting documentation should be compiled into a single pdf document and e-mailed toDr. David Shafer, Assistant Dean of the Graduate School ().The deadline to receive nominations for the July 1, 2016 – December 31, 2016 grant period is May 16, 2016.

1.Personal Data

Name of Nominee: ______

Last FirstMiddle

Student ID Number: ______

Mailing Address: ______

Street/Box

______

City/Town StateZip

Home Telephone: Office Phone:

E-Mail Address: ______Cell Phone: ______

Department and/or graduate program: ______

Committee Chair: ______

Committee Chair’s E-Mail Address: ______

Committee Chair's Mailing Address:______

Street/Box

______

City/Town StateZip

PresentStatus: U.S. Citizen  Permanent Resident of USA

Gender:  FemaleMale

Ethnicity (optional): African AmericanAlaskan Native/Pacific Islander

 American IndianAsian

HispanicWhite

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Graduate School Doctoral Dissertation Completion Grant Nomination Form

7/1/2016-12/31/2016

2.Education

Name of School/
Location / Attendance / Degree Received
From / To / Degree / Major / Date

Graduate Cumulative GPA:

3.Statement of Nomination

I, , hereby nominate for a

(Committee Chair) (Nominee)

Doctoral Dissertation Completion Grant.

I certify that the nominee:

  1. Has met all course requirements and passed preliminary written and oral exams;
  2. Will complete all research and analysis for the dissertation by July 1, 2016 and that all that remains to complete itis the writing of the dissertation.

Signed Date ______

Committee Chair

Signed Date______

Department Head or Director of Graduate Programs

(Appropriate authorizing official should sign)

4.Statement from Nominee

  1. I understand that I must have completed all research and analysis for my dissertation prior to the grant start date and that all that will remain as of July1, 2016 is the writing of the dissertation. (Grant offers may be withdrawn if research and analyses are not complete by the grant start date.)
  1. I will not hold a TA or RA or outside employment during the grant period indicated above.
  1. I will register full time during the period of the grant.
  1. In accepting this grant, in addition to the requirementsof my graduate program, I will participate in the following activities:

1.Attend support group meetings and writing workshop with other awardees;

2.Meet regularly with a designated dissertation writing coach;

3.Actively support other grantees in meeting the shared goal of completing

their dissertations;and

4.Dedicate the 6-month grant period to finishing the dissertation.

  1. I understand that the Grant will provide a 6-month stipend in the amount of $10,000,as well as tuition and health insurance.

Signed Date ______

Nominee

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