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 Form Approved 

 OMB No. 1840-0781

 Expiration Date: XX/XX/XXXX

UNITED STATES DEPARTMENT OF EDUCATION

OFFICE OF POSTSECONDARY EDUCATION

JACOB K. JAVITS FELLOWSHIP PROGRAM

(Title VII, Part A, Higher Education Act of 1965, as amended)

JACOB K. JAVITS ANNUAL STUDENT ACTIVITIES REPORT

Dear Jacob K. Javits Fellow:

The U.S. Department of Education is requesting performance information on current Javits 

Fellows who are completing this academic year. In compliance with the Government 

Performance and Results Act (GPRA), the information you provide will assist program staff in 

tracking time-to-degree completion, the graduation rate, the employment status upon graduation 

of individual fellows, as well as the Federal cost per terminal degree (Ph.D./M.F.A.) awarded.

As you know, the purpose of the Javits Fellowship is to provide financial assistance to students 

who demonstrate superior academic ability and achievement, exceptional promise, and financial 

need to undertake graduate study leading to a doctoral degree or master's degree in which the 

master's degree is the terminal highest degree being awarded in the selected field of study. Data 

collected from the Jacob K. Javits Annual Student Activities Report will be used to measure how 

successfully the program is meeting GPRA requirements. The two GPRA performance measures 

for the Javits Program are:

1. Time to degree completion for Javits fellows will be less than the national average of 7.5 

years

2. The percentage of Javits Fellows obtaining graduate degrees will be greater than the 

national average (30%)

The GPRA efficiency measure for the Javits program is: 

1. The Federal cost per terminal degree (Ph.D., M.F.A.) awarded for the Javits Fellowship 

Program

Other data collected by the report will provide valuable information on how fellows finance the 

remainder of their graduate education beyond the 4-year performance period of the Javits 

fellowship and the types of employment they plan to pursue.

The online report and instructions will be accessible via the following URL on [insert date]: 

[insert URL]. 
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Please submit this report no later than [insert date]. If you have any questions, please feel free to 

contact me immediately at Carmen.Gordon@ed.gov or (202) 219-7138.

Congratulations on all of your accomplishments as a Fellow. I wish you continued success in 

your academic and professional efforts throughout the remainder of your fellowship tenure. 

Thank you for your prompt attention regarding this matter.

Sincerely, 

Carmen Gordon

Program Specialist

Jacob K. Javits Fellowship Program
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UNITED STATES DEPARTMENT OF EDUCATION

OFFICE OF POSTSECONDARY EDUCATION

JACOB K. JAVITS FELLOWSHIP PROGRAM

(Title VII, Part A, Higher Education Act of 1965, as amended)

INSTRUCTIONS FOR COMPLETING THE ANNUAL STUDENT ACTIVITIES 

REPORT

1. Please provide your first and last name in the space provided.

2. Please provide your current and permanent mailing addresses in the space 

provided.

3. Please provide your e-mail address in the space provided.

4. Please select one of the options shown below to denote your race in the space 

provided.

Race: ______ American Indian or Alaska Native

______ Asian

______ Black or African American

______ Native Hawaiian or Other Pacific Islander 

______ White

5. Please select one of the options shown below to denote your ethnicity in the 

space provided.

Ethnicity: ______ Hispanic or Latino

______ Not Hispanic or Latino

6. Please select one of the options shown below to denote your gender in the 

space provided.

Gender: ______ Female ______ Male

7. Please list the name of the institution administering the Javits grant award

and your fellowship in the space provided. 

8. Please indicate the year and the term you entered your graduate program in 

the space provided. 

9. Please select one of the options shown below to denote the graduate degree 

program that you are pursuing in the space provided.
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Degree Program: ______ 2-year MFA (Master of Fine Arts) degree

______ 3-year MFA (Master of Fine Arts) degree

______ PhD

10. In the space provided, please indicate your current academic status by

 selecting the applicable status for either the MFA Degree or PhD Degree

 classification areas. 

MFA: ______Completed 1st Year Coursework

______Completed 2nd Year Coursework

______Completed Thesis/Portfolio/Performance or

recital

PhD: ______Enrolled but not yet advanced to PhD candidacy

______Passed preliminary exams and advanced to PhD

______Has received Ph.D.

11. Please provide the month and year of your expected graduation in the space

provided. 

12. Please indicate the total number of years you received Javits funding in the 

space provided.

13. In the space provided, please describe the research activities, teaching 

experience or other activities in which you have participated during the past 

year. 

14. In the space provided, please provide specific examples of conferences and 

you have attended and publications that you have presented during the past 

year. 

 

15. In the space provided, if you were engaged in a part-time work experience 

during the past year, please indicate the type of employment.

Please discuss briefly your part-time work experience in the additional space 

provided.

16. In the space provided, if you took an Interruption of Study, please indicate 

the purpose of the Interruption and discuss the activities in which you 

participated.

17. In the space provided, please discuss your current goals and employment 

plans upon earning your degree. 
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18. Please indicate whether or not you have submitted the FAFSA for the [insert 

year]-[insert year] academic year in the space provided. 

19. In the space provided, please explain the impact that receiving a Javits 

fellowship had upon your decision to enter graduate school. 

20. In the space provided, please explain the impact the Javits fellowship had 

upon your choice of academic area at your institution.

21. In the space provided, please indicate whether or not you had other

 fellowship offers at the time you were awarded the Javits fellowship.

If “Yes,” please specify the other offers you received in the additional space

provided.

If “Yes,” please explain what prompted your decision to accept the Javits

fellowship over your other fellowship offers in the space provided.
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UNITED STATES DEPARTMENT OF EDUCATION

OFFICE OF POSTSECONDARY EDUCATION

JACOB K. JAVITS ANNUAL STUDENT ACTIVITIES REPORT

[INSERT FISCAL YEAR]

Instructions: For [insert year] Cohort Javits fellows funded from September 1, 

[insert year] through August 31, [insert year], please enter all of the information 

requested below. 

1) Student’s Name: _________________ __________________

First Name Last Name

2) Mailing Address: 

Current Mailing Address: 

Permanent Mailing Address: 

3) E-Mail Address: ____________________________________

4) Race: ______ American Indian or Alaska Native

______ Asian

______ Black or African American

______ Native Hawaiian or Other Pacific Islander 

______ White

5) Ethnicity: ______ Hispanic or Latino

______ Not Hispanic or Latino

6) Gender: ______ Female ______Male
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7) Institution Name: _________________________________________

8) Year and term you entered institution’s graduate program:

_______Year _______Term (i.e., Fall Term/ Spring Term)

9) Please select one of the options shown below to denote the graduate degree 

program that you are pursuing in the space provided.

Degree Program: ______ 2-year MFA (Master of Fine Arts) degree

______ 3-year MFA (Master of Fine Arts) degree

______ PhD

10) Please indicate your current academic status by selecting the applicable status

 for either the MFA Degree or PhD Degree classification areas. 

MFA: ______Completed 1st Year Coursework

______Completed 2nd Year Coursework

______Completed Thesis/Portfolio/Performance or

recital

PhD: ______Enrolled but not yet advanced to PhD Candidacy

______Passed preliminary exams and advanced to PhD

______Has received Ph.D.

11) Your Expected Date of Graduation: _________Month __________Year

12) Total Number of Years You Received Javits Funds: __________________

13) Describe the research activities, teaching experience or other activities in which

 you have participated during the past year.

 

14) Please provide specific examples of conferences you have attended and

 publications that you have presented during the past year:

15) If you were engaged in a part-time work experience during the past year, please
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 indicate the type of employment: ________________________________________

 ___________________________________________________________________

 Please discuss briefly your part-time work experience.

16) If you took an Interruption of Study, please indicate the purpose of the

 Interruption and discuss the activities in which you participated. 

 

17) Please discuss your current goals and employment plans upon earning your

 degree.

 

18) Have you submitted the FAFSA for the [insert year] – [insert year] academic 

year?

_____ Yes _____ No

19) Please explain the impact that receiving a Javits fellowship had upon your

 decision to enter graduate school:
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20) Please explain the impact that receiving a Javits fellowship had upon your

 choice of academic area at your institution:

21) At the time you were awarded a Javits fellowship, did you have other fellowship

 offers?

____ Yes ____ No

 If “Yes,” please specify which offers you had below:

 

If “Yes,” please explain what made you decide to accept the Javits fellowship

 over your other fellowship offers:

Disclosure of 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. Public 

reporting burden for this collection of information is estimated to average 3 hours per response, 

including time for reviewing instructions, searching existing data sources, gathering and 
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maintaining the data needed, and completing and reviewing the collection of information. The 

obligation to respond to this collection is required to obtain or retain benefit (34 CFR Part 74.51, 34

CFR Part 75, Section 75.118, 75.720(a) and 75.720 (b)). Send comments regarding the burden 

estimate or any other aspect of this collection of information, including suggestions for reducing 

this burden, to regulations.gov during the public comment period for this collection of information.

If you have specific questions about the form, instrument or survey, please contact (202) 219-7138.

CONFIDENTIALITY STATEMENT

Responses to this data collection will be used only for reporting purposes. The reports prepared for this study will summarize findings 

to be presented to Congress and other relevant review parties. Any collected data made public would only be presented in aggregate, 

and would not include personal information.