1 **Form A pproved**  **OM B 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 Edu cation 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 co mpliance 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 F ederal 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 o f 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 an d instructions will be accessible via the following URL on [insert date]: [insert URL].2

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 al l of your accomplishments as a F ellow . I wish you continued success in your academic and professional efforts throughout the remainder of your fellowship tenure. Thank you for your pr ompt attention regarding this matter. Sincerely, Carmen Gordon Program Specialist Jacob K. Javits Fellowship Program3 **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 addr**  **esses 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 ______ Blac**  **k 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.**4 **Degree Program: ______ 2**  **- year MF**  **A (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**  **c lassification 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 advan**  **ced 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 descri**  **be 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 presente**  **d 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.**5

**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 dec**  **ision 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 fellowshi**  **p offers in the space provided.**6 **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 Septembe**  **r 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:** 

**Permane nt 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) E thnicity:**  **______ Hispanic or Latino**

**______ Not Hispanic or Latino 6) Gender:**  **______ Female ______Male** 7

**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 -**  **y ear 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** 

**__ ____**  **C om**  **pleted 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 Graduat**  **ion: _________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**8

**indicate th e 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:** 9

**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 pers**  **ons are required to respond to a collection of information unless such collection display**  **s 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 in**  **structions, searching existing data sources, gathering and**10 **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 y**  **ou 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 p repared 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 agg regate, and would not include personal information.