Form 1 SDS App

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Overview

Program Specific Forms
Recruitment and Retention
More than one race combination

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Sheet 1: Program Specific Forms

PROGRAM SPECIFIC FORMS							Notes
Application Tracking #:
Choose Your Discipline
A. FULL-TIME STUDENTS IN YOUR PROGRAM FOR ACADEMIC YEAR 20XX-20XX (XX/XX/XX-XX/XX/XX) AND THEIR RACIAL/ETHNIC BACKGROUNDS
Race/Ethnicity	Full-Time Students Enrolled
	1. Hispanic/Latino			2. Non-Hispanic/Non-Latino
a. American Indian/Alaska Native
b. Black or African American
c. Asian
c. Native Hawaiian or Pacific Islander
d. White
e. More Than One Race
f. Race Not Reported
Grand Total (Sum of Hispanic/Latino Students and Non-Hispanic/Non-Latino Students)	#REF!
B. TOTAL FULL-TIME ENROLLMENT AND FULL-TIME DISADVANTAGED ENROLLMENT BY CLASS YEAR FOR STUDENTS IN YOUR PROGRAM FOR ACADEMIC YEAR 20XX-20XX (XX/XX/XX-XX/XX/XX)
Class Year	Total Full-Time Class Enrollment			Total Full-Time Disadvantaged Enrollment
First Year
Second Year
Third Year
Fourth Year
Fifth Year
Sixth Year
Total (Note: Total Full-Time Class Enrollment must be equal to grand total of full time students above)	0			0
Of the number of full-time disadvantaged, how many are economically disadvantaged?
C. TOTAL NUMBER OF FULL-TIME STUDENTS GRADUATED, TOTAL NUMBER OF FULL-TIME STUDENTS GRADUATED THAT RECEIVED SDS FUNDS, AND OF THE NUMBER OF FULL-TIME DISADVANTAGED GRADUATES, HOW MANY ARE ECONOMICALLY DISADVANTAGED FROM YOUR PROGRAM FOR ACADEMIC YEAR 20XX-20XX (XX/XX/XX - XX/XX/XX)
Total Full-Time Graduates
Of the number of full time graduates, number of graduates that received SDS
Full-Time Disadvantaged Graduates
Of the number or Full-Time Disadvantaged, how many are economically disadvantaged?
D. GRADUATES FROM YOUR PROGRAM SERVING IN PRIMARY CARE AND/OR MEDICALLY UNDERSERVED COMMUNITIES
Primary Care
Number of full-time graduates during 20XX - 20XX				0
Of the number of full-time graduates (above), enter the number of graduates serving in primary care during 20XX - 20XX
Of the number of full-time graduates serving in primary care (above), enter the number of graduates that received SDS funds
Medically Underserved Communities
Number of full-time graduates during 20XX - 20XX
Of the number of full-time graduates (above), enter the number of graduates practicing in medically underserved communities 20XX - 20XX
Of the number of full-time graduates practicing in medically underserved communities (above), enter the number of graduates that received SDS funds
E. COST OF TUITION FOR FULL-TIME STUDENTS FOR THIS PROGRAM
Cost of Tuition for Full-Time Students for This Program
F. LENGTH OF PROGRAM
Length of time (in years) necessary to complete this program (Example: Nursing Baccalaureate, select 4)
G. ACCREDITATION
Name of Accrediting Body
Expiration Date (mm/dd/yyyy)
H. POINT OF CONTACT
Name
Title
Phone Number
Email
I. REQUESTED AWARD AMOUNT
What is your total need amount?
J. STUDENTS SUPPORTED
How many students do you plan to support with the requested award amount?
K . PUBLIC OR NON-PROFIT INSTITUTION
Is your school/program an accredited public or an accredited non profit institution?
L. CERTIFICATION AND ELIGIBILITY QUESTIONS
Will preference be given to students for whom the cost of attendance would constitute a severe financial hardship?
Describe the school's methods and standards for setting the amount of the scholarships.
Select the method (including frequency) the program will use to disburse the SDS scholarships to students. Check all that apply				[ ] Disburse funds directly to students [ ] Apply funds towards tuition expenses [ ] Disburse funds to students monthly [ ] Disburse funds to students quarterly [ ] Disburse funds to students per semester [ ] Disburse funds to students annually
How will you use the SDS scholarship funds?				[ ] Tuition [ ] Fees and Other Reasonable Educational Expenses [ ] Reasonable Living Expenses
OMB No.: 0915-0149 Expiration Date: 11/30/2013
M. COMMUNITY COLLEGE QUESTION
Is your school a community college?
N. RECRUITMENT AND RETENTION ELIGIBILITY
Is your school currently carrying out a program to recruit and retain students from disadvantaged backgrounds, including students who are members of racial and ethnic minority groups?

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Sheet 2: Recruitment and Retention

O. RECRUITMENT ACTIVITIES
Please indicate what recruitment activities for disadvantaged students that apply to your program
High School Recruitment
General
	College Fairs
	Summer camps/programs for high school students to receive information about programs offered
	Other. Please describe
	Not Applicable
Specifically targeting/recruiting disadvantaged students
	Attending college fairs in areas with high percentages of disadvantaged students locally or on a broader scale
	Training recruiters specifically to answer questions and provide information to disadvantaged students.
	Providing specifically designed information packets on programs and accommodations your school offers for disadvantaged students
	Prep Courses for disadvantaged high school students interested in careers in the health professions
	Other. Please describe
	Not Applicable
College Level Recruitment
	Recruitment from community colleges in disadvantaged areas
	Community College joint admissions programs for disadvantaged students
	Other. Please describe
	Not Applicable
Specifically targeting/recruiting disadvantaged students
	Attending college fairs in areas with high percentages of disadvantaged students locally or on a broader scale
	Training recruiters specifically to answer questions and provide information to disadvantaged students.
	Providing specifically designed information packets on programs and accommodations your school offers for disadvantaged students
	Prep Courses for disadvantaged high school students interested in careers in the health professions
	Other. Please describe
	Not Applicable
Application Services
	Online programs that wave or assist with application fees for disadvantaged students
	Other. Please describe
	Not Applicable
Open Houses
	Booths or presentations on resources for disadvantaged students
	Targeted advertisements for open houses or other programs in areas with high percentage of disadvantaged students
	Other. Please describe
	Not Applicable
P. RETENTION AND/OR MENTORING ACTIVITIES
Please indicate what retention/mentoring activities for disadvantaged students apply to your program
Individual or Group Peer Mentor Program (big brother/big sister)
	Open to all
	Specifically designed for disadvantaged students
	Placing students in peer support or networks and groups
	Other. Please describe
	Not Applicable
Individual Staff/Advisor Mentor Program
	Open to all
	Specifically designed for disadvantaged students
	Other. Please describe
	Not Applicable
Specialized pre-attendance orientation for disadvantaged students
	Team and camaraderie building activities to help students feel included in the school
	Educate disadvantaged students on how to best use the accommodations and resources the school provides
	Introduce forge contacts between disadvantaged students and faculty/staff (ex: Heads of departments, Tutors, Financial aid and/or advisors)
	Specialized welcome packets for disadvantaged students with additional information on available recourses and programs that will help them succeed
	Other. Please describe
	Not Applicable
College Skills Development and Review Programs
	Summer or pre-matriculation sessions in a classroom setting teaching disadvantaged students skills that they will need to be successful (eg: study skills, note taking skills, test taking skills, and/or time management skills)
	Summer or pre-matriculation classes for disadvantaged students to review and strengthen prerequisite knowledge of the course work
	Individual assessment and profile of disadvantaged students strengths and weaknesses with advisor and plan for development of skills
	Other. Please describe
	Not Applicable
Early identification for students at risk
	Identify students who are falling behind early and provide assistance for them in furthering their academic career
	Develop individualized plans for struggling disadvantaged students to ensure success/coordination support
	Provide learning specialists for disadvantaged students who can identify possible learning disabilities or assess strengths and weaknesses.
	Seminars and lectures specifically for disadvantaged students
	Other. Please describe
	Not Applicable
Group or Individual Tutoring Services
	Provide faculty or peer tutors to disadvantaged students
	Tutors specifically trained to help students faced with struggles from a disadvantaged background.
	Financial mentoring/tutoring
	Other. Please describe
	Not Applicable
Child Care Support
	Free
	Partially subsidized
	Other. Please describe
	Not Applicable
Professional Opportunities
	Free
	Partially subsidized
	Other. Please describe
	Not Applicable

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Sheet 3: More than one race combination

Hispanic or Latino Students
MORE THAN ONE RACE COMBINATION FOR HISPANIC OR LATINO
STUDENTS – Sub page
Legend
AIAN	American Indian or Alaska Native	Asian	Asian
Black	Black or African American	NHOPI	Native Hawaiian or Other Pacific Islander
White	White
Combination of Two Races	1. Hispanic/Latino	2. Non-Hispanic/Non-Latino
AIAN and Black
AIAN and White
Asian (not underrepresented) and AIAN
Asian (underrepresented) and AIAN
Asian (not underrepresented) and Black
Asian (underrepresented) and Black
Asian (not underrepresented) and NHOPI
Asian (underrepresented) and NHOPI
Asian (not underrepresented) and White
Asian (underrepresented) and White
Black and White
NHOPI and AIAN
NHOPI and Black
NHOPI and White
Combination of Three Races	1. Hispanic/Latino	2. Non-Hispanic/Non-Latino
AIAN and Asian (not underrepresented) and Black
AIAN and Asian (underrepresented) and Black
AIAN and Asian and NHOPI
AIAN and Asian (not underrepresented) and NHOPI
AIAN and Asian (underrepresented) and NHOPI
AIAN and Asian and White
AIAN and Asian (not underrepresented) and White
AIAN and Asian (underrepresented) and White
AIAN and Black and NHOPI
AIAN and Black and White
AIAN and NHOPI and White
Asian (not underrepresented) and Black and NHOPI
Asian (underrepresented) and Black and NHOPI
Asian (not underrepresented) and Black and White
Asian (underrepresented) and Black and White
Asian (not underrepresented) and NHOPI and White
Asian (underrepresented) and NHOPI and White
Black and NHOPI and White
Combination of Four Races	1. Hispanic/Latino	2. Non-Hispanic/Non-Latino
AIAN and Asian (not underrepresented) and Black and NHOPI
AIAN and Asian (underrepresented) and Black and NHOPI
AIAN and Asian (not underrepresented) and Black and White
AIAN and Asian (underrepresented) and Black and White
AIAN and Asian (not underrepresented) and NHOPI and White
AIAN and Asian (underrepresented) and NHOPI and White
AIAN and Black and NHOPI and White
Asian and Black and NHOPI and White
Combination of Five Races	1. Hispanic/Latino	2. Non-Hispanic/Non-Latino
AIAN and Asian (not underrepresented) and Black and NHOPI and White
AIAN and Asian (underrepresented) and Black and NHOPI and White
Question No:3:- Non-Hispanic or Non-Latino Students
MORE THAN ONE RACE COMBINATION FOR NON HISPANIC OR NON
LATINO STUDENTS – Sub page
Combination of Two Races	1. Hispanic/Latino	2. Non-Hispanic/Non-Latino
AIAN and Black
AIAN and White
Asian (not underrepresented) and AIAN
Asian (underrepresented) and AIAN
Asian (not underrepresented) and Black
Asian (underrepresented) and Black
Asian (not underrepresented) and NHOPI
Asian (underrepresented) and NHOPI
Asian (not underrepresented) and White
Asian (underrepresented) and White
Black and White
NHOPI and AIAN
NHOPI and Black
NHOPI and White
Combination of Three Races	1. Hispanic/Latino	2. Non-Hispanic/Non-Latino
AIAN and Asian (not underrepresented) and Black
AIAN and Asian (underrepresented) and Black
AIAN and Asian and NHOPI
AIAN and Asian (not underrepresented) and NHOPI
AIAN and Asian (underrepresented) and NHOPI
AIAN and Asian and White
AIAN and Asian (not underrepresented) and White
AIAN and Asian (underrepresented) and White
AIAN and Black and NHOPI
AIAN and Black and White
AIAN and NHOPI and White
Asian (not underrepresented) and Black and NHOPI
Asian (underrepresented) and Black and NHOPI
Asian (not underrepresented) and Black and White
Asian (underrepresented) and Black and White
Asian (not underrepresented) and NHOPI and White
Asian (underrepresented) and NHOPI and White
Black and NHOPI and White
Combination of Four Races	1. Hispanic/Latino	2. Non-Hispanic/Non-Latino
AIAN and Asian (not underrepresented) and Black and NHOPI
AIAN and Asian (underrepresented) and Black and NHOPI
AIAN and Asian (not underrepresented) and Black and White
AIAN and Asian (underrepresented) and Black and White
AIAN and Asian (not underrepresented) and NHOPI and White
AIAN and Asian (underrepresented) and NHOPI and White
AIAN and Black and NHOPI and White
Asian and Black and NHOPI and White
Combination of Five Races	1. Hispanic/Latino	2. Non-Hispanic/Non-Latino
AIAN and Asian (not underrepresented) and Black and NHOPI and White
AIAN and Asian (underrepresented) and Black and NHOPI and White