Form 3: Student Demographic Information

1410 Engineering Drive, Room 264

university of wisconsin – madison, madison, wi • 53706

Phone: (608) 263-1138 • Fax: (608) 890-0462 http://wiscamp.engr.wisc.edu/

This form has two purposes. The first is to gather basic information that contributes to program planning and is required by the National Science Foundation as a conditionof funding. The second is to provideWiscAMP a way to contact students in the future. We look forward to learning about students’ academic progress and their transitions into careers. This type of information also helps us improve programming. Finally, we understand our obligation to make sure that personal information is protected and we are prepared to meet it.

There are three sections to the form. Section 1 is used to collect grant/project related information. It should be pre-filled by the PI or the PI’s agent before the form is given to students to complete. Section2 is used to gather information about student characteristics. It should generally be completed by the student, but can be completed by the PI or the PI’s agent at need. Section 3 gathers contact information; it can only be completed by the student.

Section 1: Should be prefilled by PI or PI’s agent

Grant Title:______

Activity Title (If different than grant title): ______

Semester/ Date of Participation:______

Student’s Name (First):______(Middle Initial): ______(Last): ______

Name of Project Mentor:______

WiscAMP Financial Support (Check all that apply):

□ Academic Year □ Summer □ None

Section 2: Should be completed by the student; but can be completed by PI or PI’s agent

Student Social Security Number: ______

Note: this is an optional data element. It is your choice whether to provide it.

Major: (Choose Only One – Look at The Items On the Back Before Choosing!)

□Agricultural Sciences (e.g., Animal Sciences, Food Sciences and Technology, Soil Sciences)

□Natural Resources and Conservation (e.g., Natural Resources Management, Forestry, Wildlife Science & Management)

□Architecture (e.g., Architecture, Environmental Design)

□Computer & Information Sciences (e.g., Computer Science, Information Science/Studies)

□Engineering (e.g., Architectural Engineering, Chemical Engineering, Electrical Engineering, Mechanical Engineering, Engineering Physics)

□Engineering Technologies (e.g., Construction Engineering Technologies, Nanotechnology)

□Biological Sciences (e.g., Biochemistry, Zoology, Physiology, Ecology & Population Biology, Genetics)

□Mathematics (e.g., Mathematics, Statistics)

□Interdisciplinary Studies (e.g., Systems Science and Theory, Nutrition Science, Human Biology, Biopsychology, Marine Sciences)

□Physical Sciences (e.g., Astronomy, Chemistry, Geosciences, Physics, Material Sciences)

□Business and Management (only Management Sciences and Quantitative Methods)

□Other STEM, Please Specify! ______

□Undeclared or Non-STEM

Class Standing: □ Freshman □ Sophomore □ Junior □ Senior □ Graduate

Graduating this Year: □ Yes □ No

GPA(cumulative):______

If you haven’t completed any college course work or attend an institution that doesn’t grade course work, enter 0

Date of Birth: ______

Gender:□ Male□Female□ Other

Race (mark any that applies):

□ Black or African American□ Native American□ Native Hawaiian or Other Pacific Islander

□ Alaska Native□ Asian □ White□ Other/Not Applicable

Ethnicity/Hispanic:

□ Hispanic or Latino□ Not Hispanic or Latino

Ethnicity/Southeast Asian (Hmong, Cambodian, Lao, or Vietnamese):

□Southeast Asian □ Not Southeast Asian

Disability Status (mark “yes” if you are deaf or have serious difficulty hearing, blind or have serious difficulty seeing, have serious difficulty walking or climbing stairs, or have other serious difficulties related to a physical, mental, or emotional condition):

□Yes (have a serious disability) □No (do not have a serious disability) □Do not wish to provide information

Home Institution (if different from the location of this project):

______

Section 3: This section can only be completed by the student. As we hope to contact you in the future, we ask you to provide information that you think will give us the best chance of contacting you over the next several years. Providing the requested information is voluntary.

University/College E-mail:______

Personal E-mail:______

Mailing Address:

Form 3, 2016

"This material is based upon work supported by the National Science Foundation under Grant Number 1400815"