Student Selection Forms

Attachment 4

Eligible Student Selection Form

ELIGIBLE STUDENT SELECTION FORM
1) Applicant’s name:			Last |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
			First |___|___|___|___|___|___|___|___|___|___|___| Middle Initial |___|
	[ID #]								Office use only
			5-digit ID number from Consent Form: |___|___|___|___|___|
2) Current date: Month |___|___| Day |___|___| Year 20|___|___|						3) Expected date of program entry if selected: Month |___|___| Day |___|___| Year 20|___|___|
4) Applicant’s address:			Number and Street |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
			Apartment number: |___|___|___|___|
			City |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
			State: |___|___| Zip code: |___|___|___|___|___|
			Telephone: (|___|___|___|) |___|___|___| - |___|___|___|___| (area code)
5) Social Security Number: |___|___|___| - |___|___| |___|___|___|___|						6) Date of birth: Month |___|___| Day |___|___| Year 19|___|___|
7) 2007–2008 school year:
Name of school |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
City of school |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| State: |___|___|
Grade level |___|___|
8) Program eligibility:
Family income is at or below 150 percent of poverty level							 1 Yes  2 No  3 Don’t Know
Potential first generation college student							 1 Yes  2 No  3 Don’t Know
Student has completed 10th grade							 1 Yes  2 No
9) Higher-risk status:
Student has completed 9th grade					 1 Yes  2 No
8th grade proficiency in reading/language arts					 1 Proficient  2 Not proficient  3 Don’t Know
8th grade proficiency in mathematics					 1 Proficient  2 Not proficient  3 Don’t Know
8th grade mathematics class					 1 Pre-algebra or higher  3 Don’t Know  2 Lower than pre-algebra
Grade point average in most recent completed school year					 1 Above 2.5  3 Don’t Know  2 2.5 or less
10) Does the applicant have any siblings currently enrolled in Upward Bound?  1 Yes  2 No
11) Student Selection Rating:				 1 More likely to select in the absence of random assignment  2 Less likely to select in the absence of random assignment

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 The valid OMB control number for this information collection will be entered after clearance. The time required to complete this information collection is estimated to average 15 minutes per response per student, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

Abt Associates Inc. Eligible Student Selection Form 1