Upward Bound and Upward Bound Math Science APR form

4

OMB Approval No.: 1840-XXXX

Expiration Date: xx/xx/xxxx

Upward Bound (UB) and Upward Bound Math-Science (UBMS)

Annual Performance Report

Program Year 2015–16

Authority: Public Law 102-325, as amended.

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 17 hours per response, including time for reviewing instructions, searching existing data sources, gathering and 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 (Title IV, Sections 402A and 402C of the Higher Education Act of 1965, as amended; the program regulations in 34 CFR 645; and the Education Department General Administrative Regulations (EDGAR) in 34 CFR 74.51, 75.720, and 75.732). 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 Federal TRIO Programs, U.S. Department of Education, 400 Maryland Avenue S.W., Washington, D.C. 20202.

SECTION I, Part 1 – PROJECT IDENTIFICATION, CERTIFICATION, AND WARNING

1. Identification (all fields with an asterisk [*] are mandatory):

1. PR/Award Number: [will be prepopulated]

2. Name of Grantee Institution/Agency: [will be prepopulated]

3. Address: Campus: [address will be prepopulated]

Street:*

City:*

State:* [dropdown box] Zip:*

4. Name of Project Director: [section 4 will be prepopulated]

Prefix: [dropdown box allowing choice among Mr., Mrs., Ms., Dr., Sister, Father]

First Name:* MI: Last Name:*

4. Telephone Number:* ext.: [section 5 will be prepopulated]

Fax Number: ext.:

E-mail Address:*

6. Report Period: [will be prepopulated]

7. Type of Project: [will be prepopulated]

8. *For UBMS projects only, please indicate whether project is

• regional (i.e., serves at least two states) or

• non-regional (i.e., operates within a state or a locality).

8. *Project Characteristics

   1. Summer residential program (select one below)

____ Yes ____ No

____ Some participants are residential, others commute

2. Number of weeks of summer program (insert #) ______

3. Frequency of academic year contacts between project staff and participants (select only one)

____Weekly

____Twice a month

____Once a month

____Quarterly

____No face-to-face contact

____Other: __________________________________

8. Data Entry Person:

First Name:* MI: Last Name:*

Telephone Number:* ext.:

If you would like to receive an e-mail confirmation upon receipt of your Annual Performance Report, please enter your e-mail address:

2. Certification

The Project Director and Certifying Official are required to sign and date Section I, Part 1 of the 2015–16 Annual Performance Report form to certify the accuracy and completeness of the information submitted electronically; please use the Print button provided on the Submit page. Once the form has been signed, it should be scanned so that it can be uploaded using the functionality of the APR site. Only Section I, Part 1 should be uploaded—not any other portion of the report.

Please review the information in this section for accuracy and make needed changes before proceeding to the next section of the report form.

 I have verified the information in this section.

Warning

Any person who knowingly makes a false statement or misrepresentation on this report is subject to penalties which may include fines, imprisonment, or both, under the United States Criminal Code and 20 U.S.C. 1097.

Further federal funds or other benefits may be withheld under these programs unless this report is completed and filed as required by existing law (20 U.S.C. 1231a) and regulations (34 CFR 75.590 and 75.720).

SECTION I, Part 2 – Competitive Preference Priorities (If Applicable)

The 2012 UB and UBMS grant competitions established three competitive preference priorities concerning persistently lowest-achieving schools, data-based decision-making, and improvements in productivity. The Department will derive data for the first competitive preference priority, concerning projects’ service to persistently lowest-achieving schools, from the “Target School—NCES Identification Number” field (#23) in Section II, which provides identifying information on the target school attended by each participant. For the two remaining competitive preference priorities, the Department will prepopulate Section I, Part 2 with the information you submitted in the 2012–13 APR in a format that cannot be edited in the current APR. If you wish to provide any updates, please contact your program specialist.

Competitive Preference Priority #2: The Secretary encourages applicants to work with appropriate State agencies to use data from State longitudinal data systems or to obtain data from reliable third-party sources when providing information on the implementation of their UB/UBMS projects and their participants’ outcomes.

1A. Not applicable □

1B. Yes □

If “Yes,” indicate below which data systems your project utilized.

State longitudinal data systems	Third-party data systems

Competitive Preference Priority #3: The Secretary encourages applicants to design projects that serve the same or an increased number of students at a lower cost per participant while improving or keeping steady student outcomes.

3A. Not applicable □

3B. Yes □

If “Yes,” indicate below how your project achieved this productivity by increasing efficiency in the use of time, staff, money or other resources.

Resource/Measure used with increased efficiency	Improved outcome

ANNUAL PERFORMANCE REPORT (2015–16)

SECTION II -- RECORD STRUCTURE FOR PARTICIPANT LIST

FOR UPWARD BOUND AND UPWARD BOUND MATH-SCIENCE PROJECTS

Grantees must submit student files in Excel or CSV format. Column names must match the "Database column names" provided in column four below, and grantees must follow instructions in the "Valid field content" column. For additional information on how to submit data, please see "How May the Report be Submitted?" in the instructions for the APR.

Subsection	Field no.	Field name	Database column name	Valid field content	Data for field must not change from reporting year to reporting year	Grantee must check field each reporting year to see if update is needed
Project identifiers (pre-populated)	1	PR/Award Number	PR	Number in Block 5 of the project’s Grant Award Notification. Include only the eleven character PR/Award Number that begins as follows: Upward Bound: P047A _ _ _ _ _ _ Upward Bound Math-Science: P047M _ _ _ _ _ _	These fields are pre-populated and thus do not need any checkmarks.	These fields are pre-populated and thus do not need any checkmarks.
Project identifiers (pre-populated)	2	Batch Year	BatchAY	2015 for project year 2015–16	These fields are pre-populated and thus do not need any checkmarks.	These fields are pre-populated and thus do not need any checkmarks.
Project identifiers (pre-populated)	3	Program Type	Type	1 = Upward Bound 2 = Upward Bound Math-Science	These fields are pre-populated and thus do not need any checkmarks.	These fields are pre-populated and thus do not need any checkmarks.
Participants’ demographic information	4	Social Security Number	SSN	001010001 to 999999998 000000000 = Unknown Please format the SSN in nine digits greater than 0 without using any characters (letters, hyphens) in the number (e.g., 123456789). Do not include any other forms of ID in this field and do not use SSNs of parents or siblings. So as to allow participants' records to match across years, this data must match your 2014–15 APR (except for students new in 2015–16).	✔
Participants’ demographic information	5	Student’s Last Name	LastNM	0 to 9 Uppercase A to Z . (period) ’(apostrophe) - (hyphen) Last name will be justified with an uppercase A-Z in first position. Please do not use commas or quotation marks in this field. So as to allow participants' records to match across years, this data must match your 2014–15 APR (except for students new in 2015–16).	✔
Participants’ demographic information	6	Student’s First Name	FirstNM	0 to 9 Uppercase A to Z . (period) ’(apostrophe) - (hyphen) First name will be justified with an uppercase A-Z in first position. Please do not use commas or quotation marks in this field. So as to allow participants' records to match across years, this data must match your 2014–15 APR (except for students new in 2015–16).	✔
Participants’ demographic information	7	Student’s Middle Initial	MI	Uppercase A to Z; only one character Blank = No response So as to allow participants' records to match across years, this data must match your 2014–15 APR (except for students new in 2015–16).	✔
Participants’ demographic information	8	Student’s Date of Birth	DOB	Format is MM/DD/CCYY, e.g., 01/01/1990 MM = 01 - 12 DD = 01 - 31 CC = 19-20 YY = 00-99 00/00/0000 = Unknown Please make every effort to identify the student’s precise date of birth. So as to allow participants' records to match across years, this data must match your 2014–15 APR (except for students new in 2015–16).	✔
Participants’ demographic information	9	Gender	GenderCD	1 = Male 2 = Female 0 = Unknown/Not disclosed
Participants’ demographic information	10	Ethnicity – Hispanic	Ethnic	Participant is identified as Hispanic/Latino. 1 = Yes 2 = No Please see instructions for additional detail on this field.
Participants’ demographic information	11	Race – American Indian/Alaskan Native	Race1	Participant is identified as American Indian/Alaskan Native. 1 = Yes 2 = No Please see instructions for additional detail on this field.
Participants’ demographic information	12	Race – Asian	Race2	Participant is identified as Asian. 1 = Yes 2 = No Please see instructions for additional detail on this field.
Participants’ demographic information	13	Race – Black or African American	Race3	Participant is identified as Black or African American. 1 = Yes 2 = No Please see instructions for additional detail on this field.
Participants’ demographic information	14	Race – White	Race4	Participant is identified as White. 1 = Yes 2 = No Please see instructions for additional detail on this field.
Participants’ demographic information	15	Race – Native Hawaiian or Other Pacific Islander	Race5	Participant is identified as Native Hawaiian or Other Pacific Islander. 1 = Yes 2 = No Please see instructions for additional detail on this field.
Eligibility and initial selection	16	Eligibility (at time of initial selection)	EligibilityCD	1 = Low-income and first-generation 2 = Low-income only 3 = First-generation only 4 = At risk for academic failure only 5 = Low-income and at high risk for academic failure 6 = First generation and at high risk for academic failure 7 = Low-income, first-generation, and at high risk for academic failure 0 = Unknown	✔
Eligibility and initial selection	17	At Risk: Reading/Language Arts or Math Proficiency Not Achieved (at time of initial selection)	AtRiskStdTest	1 = Student did not achieve at the proficient level on State assessments in reading/language arts and/or in math 2 = Student achieved at the proficient level on State assessments in both reading/language arts and math 8 = Not applicable, student has not taken the State assessment to determine whether he or she met standard; student took assessment but results are not yet available; no suitable assessment exists; or no proficient level for assessment has been established. 9 = Not applicable, prior or continuing participant served before the 2012–17 grant cycle 0 = Unknown If a project indicated in the eligibility field (#16) that a participant met the criterion of being at high risk for academic failure, the project must have ascertained that the student met at least one criterion in the program regulations’ definition of an individual at such risk. In this field, for any participant coded 4, 5, 6, or 7 in the eligibility field, indicate whether the criterion regarding State assessments was met. Projects must use only assessments that specifically indicate whether the student achieved at the proficient level. Beginning with project year 2013–14, grantees were expected to gather data and report on all new participants in fields #17–19.	✔
Eligibility and initial selection	18	At Risk: Low Grade Point Average (at time of initial selection)	AtRiskLowGPA	1 = GPA of 2.5 or less 2 = GPA above 2.5 9 = Not applicable, prior or continuing participant served before the 2012–17 grant cycle 0 = Unknown If a project indicated in the eligibility field (#16) that a participant met the criterion of being at high risk for academic failure, the project must have ascertained that the student met at least one criterion in the program regulations’ definition of an individual at such risk. In this field, for any participant coded 4, 5, 6, or 7 in the eligibility field, indicate whether the criterion regarding low GPA was met. Select option 1 if participant’s middle school or high school GPA for the most recent school year for which grade point averages are available was 2.5 or less (on a 4.0 scale). Beginning with project year 2013–14, grantees were expected to gather data and report on all new participants in fields #17–19.	✔
Eligibility and initial selection	19	At Risk: Pre-Algebra or Algebra Course Not Successfully Completed by Beginning of 10th Grade (at time of initial selection)	AtRiskAlgebra	1 = At the beginning of 10th grade, student had not successfully completed pre-algebra or algebra course 2 = At the beginning of 10th grade, student had successfully completed pre-algebra or algebra course 8 = Not applicable, this information is not yet available due to grade at student’s initial selection 9 = Not applicable, prior or continuing participant served before the 2012–17 grant cycle 0 = Unknown If a project indicated in the eligibility field (#16) that a participant met the criterion of being at high risk for academic failure, the project must have ascertained that the student met at least one criterion in the program regulations’ definition of an individual at such risk. In this field, for any participant coded 4, 5, 6, or 7 in the eligibility field, indicate whether the criterion regarding algebra coursework was met. Beginning with project year 2013–14, grantees were expected to gather data and report on all new participants in fields #17–19.	✔
Eligibility and initial selection	20	Limited English Proficiency (at time of initial selection)	LEPEntry	1 = Yes 2 = No 0 = Unknown Please see “Definitions That Apply” in the General Instructions. The information in this field should not be changed or updated in subsequent data submissions except to correct previously entered erroneous data. For prior-year participants, if information for this field is not readily available, please use option 0.
Eligibility and initial selection	21	Disconnected Youth (at time of initial selection)	Disconnected	1 = Yes, participant meets one or more criteria in definition of disconnected youth 2 = No, participant does not meet any criterion in definition of disconnected youth 9 = Not applicable, prior or continuing participant served before the 2012–17 grant cycle 0 = Unknown “Disconnected youth” is defined in the Appendix to the FY 2013 Budget of the U.S. Government as individuals between the ages of 14 and 24 who are homeless, in foster care, involved in the juvenile justice system, or are neither employed nor enrolled in an educational institution. For further information, see “Definitions That Apply” in the General Instructions. The information in this field should not be changed or updated in subsequent data submissions except to correct previously entered erroneous data.
Eligibility and initial selection	22	Other Academic Need (at time of initial selection)	OtherNeed	3 = Low educational aspirations 7 = Lack of opportunity, support, and/or guidance to take challenging college preparation courses 8 = Lack of career goals and/or need for accurate information on careers 9 = Limited English proficiency 10 = Lack of confidence, self-esteem, and/or social skills 11 = Predominantly low-income community 12 = Rural isolation 13 = Interest in careers in math or science 14 = Other 15 = Diagnosed learning disability 16 = Need was identified in one or more of fields #17–19 17 = Prior or continuing participant served pre 2012–17 cycle w/need of low GPA and/or low achievement test scores 0 = Unknown If needed, use 14 – “Other” for categories of academic need used by your project, but not on the list of options. Please use the “Other” field sparingly. For participants first served prior to 2012–17 cycle, if information for this field is not readily available, please use option 0. The information in this field should not be changed or updated in subsequent data submissions except to correct previously entered erroneous data.
Participation and status in secondary school	23	Target School – NCES Identification Numbers, at first entry into project	NCESSchID	Provide the 12-digit NCES school identification number for the secondary school the Upward Bound student attended at time of entry into the project. For “rising” 9th graders (those first served the summer between completing 8th grade and starting 9th grade), provide the NCES school identification number for the school the student attended (or will attend) as a 9th grader. The number can be obtained from the following Web site: http://nces.ed.gov/ccd/schoolsearch 666666666666 = Private school, non-parochial 777777777777 = Parochial school 888888888888 = Home school 999999999999 = Not applicable 000000000000 = Unknown
Participation and status in secondary school	24	Date of First Project Service	ProjEntryDT	Format is MM/DD/CCYY, e.g., 09/15/2006 MM = 01 – 12 DD = 01 - 31 CC = 19 - 20 YY = 00 - 99 00/00/0000 = Unknown Accuracy is particularly important for this field. For new students, use the date the student first received service from the Upward Bound project that is submitting this report. Do not use date of acceptance into project unless that is the same as the date of first service. Students first served in the summer program should have a date of first project service no earlier than June 1. Use the original date of service at this project even if the student subsequently left and reentered. If the student transferred from another UB project, in this field give the date of first service at the project submitting the report. You do not need to provide the exact day; you may use 15 (midpoint of the month).	✔
Participation and status in secondary school	25	Grade Level, at first service	EnterGradeLV	8 = Rising 9th-grader (summer between 8th grade and 9th grade) 9 = 9th grader (not a valid option for students first receiving service in the summer program) 10 = Rising 10th grader (summer between 9th grade and 10th grade) or 10th grader 11 = Rising 11th grader (summer between 10th grade and 11th grade) or 11th grader 12 = Rising 12th-grader (summer between 11th grade and 12th grade) 13 = 12th-grader 15 = In 5th year of high school (only for students participating in a dual enrollment program that entails a 5th year of high school; includes “rising” summer period) 14 = Other 0 = Unknown Accuracy is particularly important for this field. For new students, enter the grade at the time he or she first received UB services from the project that is submitting the report. For students served first during the summer component, select “rising” 9th grader for those students who had completed 8th grade and would be entering 9th grade in the fall term. For all other students first served during the summer component, enter the grade the student would enter for the fall academic term (for example, for students first served in the summer between ninth and 10th grades, the correct code is 10). If the student was first served on any day in June, consider that student to have been first served in the summer before the coming fall grade, even if school was still in session on the student’s first day of service. For example, if your project first served a student on June 3 in the waning days of 9th grade, consider that student to have been first served in the summer before 10th grade, not in 9th grade. The code for the student would therefore be 10. If the student transferred from another UB project, in this field give the grade level at first service in the project submitting the report. (For continuing and prior-year participants, use data entered in the earlier APR.)	✔
Participation and status in secondary school	26	Deceased or Incapacitated	Deceased	1 = Deceased prior-year participant 2 = Permanently incapacitated prior-year participant 3 = Participant was served during reporting period 2015–16 but is now deceased 4 = Participant was served during reporting period 2015–16 but is now permanently incapacitated 9 = Not applicable, neither deceased nor permanently incapacitated 0 = Unknown		✔
Participation and status in secondary school	27	Participant Status, for reporting year (2015–16)	PartCD	1 = New participant during reporting period 2 = Continuing participant 3 = Reentry participant, previously served by project submitting report 4 = Prior-year participant 6 = Transfer participant in reporting year (UB participant served by another UB project, or UBMS participant served by another UBMS project, in a previous reporting year) For this report, please use the following definitions: A new participant is an individual who participated in the Upward Bound project for the first time in this reporting period and who meets the definition of participant in 34 CFR 645.6 of the program regulations. (Please refer to field #24, Date of First Project Service, on establishing the date of first service for new participants served initially in the summer program.) For Upward Bound Math-Science, a participant should be considered new if the reporting year is the first year the student has participated in the Upward Bound Math-Science project, even if the student has previously participated in a regular Upward Bound project. A continuing participant is an individual who participated in the program in both the current reporting period and the reporting period immediately preceding. A reentry participant is a former participant of the project submitting the APR who did not participate in the program during the previous 12-month reporting period, but who has received services on a continual basis during this reporting period. (In reporting years following the current one, such a participant should be coded as continuing or prior.) A prior-year participant is an individual who participated in the Upward Bound program in a previous reporting period but who has not received services on a continual basis during the current reporting period. A transfer participant is a former participant of a UB or UBMS project other than that submitting the APR who joined the current project during the reporting period, either with or without a hiatus between projects. Students who leave a UB project to join a UBMS project, or leave a UBMS project to join a UB project, are not considered transfer participants. The sum of the number of new, continuing, reentry, and transfer participants should equal the total number of participants the projects served during the reporting period.		✔
Participation and status in secondary school	28	Participation Level, for reporting year (2015–16)	PartLV	1 = Participated in academic year and summer components 2 = Participated in academic year and summer bridge 3 = Participated in academic year component only 4 = Participated in summer component only 5 = Participated in summer bridge only 6 = Not applicable, prior-year participant 0 = Unknown For students identified as new, continuing, reentry or transfer in field #27 (Participant Status), select option 1, 2, 3, 4, or 5 in this field. For students identified as prior-year in field #27, select option 6.		✔
Participation and status in secondary school	29	Served by Another Federally Funded College Access Program, for reporting year (2015–16)	FederalServed	In addition to participating in UB or UBMS during the reporting year, student received services from: 1 = Both UB and UBMS 2 = Veterans Upward Bound 3 = Talent Search 4 = GEAR UP 5 = EOC 6 = Another federally funded college access program, other than TRIO and GEAR UP 7 = More than one other federally funded college access program 8 = Not applicable, current participant served only by UB or UBMS 9 = Not applicable, prior-year participant 0 = Unknown		✔
Participation and status in secondary school	30	Grade Level, at the beginning of academic year being reported (2015–16)	StartGrade LV	8 = 8th grade 9 = 9th grade 10 = 10th grade 11 = 11th grade 12 = 12th grade 14 = In 5th year of high school (only for students participating in a dual enrollment program that entails a 5th year of high school) 13 = Enrolled in, or completed, a program of postsecondary education 15 = Other 99 = Not applicable, enrolled neither in high school nor in a program of postsecondary education 0 = Unknown Note: Use option 99 for summer bridge participants in projects with June or July start dates.		✔
Participation and status in secondary school	31	Secondary Grade Level or Postsecondary Status, at the beginning of 2016–17 (academic year following year being reported)	EndGradeLV	9 = 9th grade 10 = 10th grade 11 = 11th grade 12 = 12th grade 15 = In 5th year of high school (only for students participating in a dual enrollment program that entails a 5th year of high school) 13 = Enrolled in, or completed, a program of postsecondary education 14 = Other 99 = Not applicable, enrolled neither in high school nor in a program of postsecondary education 0 = Unknown		✔
Participation and status in secondary school	32	High School Cumulative Grade Point Average (GPA), at end of academic year being reported (2015–16)	HSGPA	0.001 to 4.000 (with exceptions noted below) 8.888 = Not applicable, the academic year ended before the participant had completed the first year of high school (for example, student first served as a rising ninth-grader in a project with reporting period beginning in September); or summer bridge student in project with summer start date who graduated from high school before academic year 2015–16 9.999 = Not applicable, prior-year participant 0.000 = Unknown GPA, or grading scale could not be converted to a four-point scale Report the GPA based on a four-point scale. If the participant’s school used a four-point scale, enter the GPA provided by the school; if not, convert other scales to four-point to the extent possible. If a student’s GPA on a four-point scale exceeded 4.000 for such a reason as completing honors or Advanced Placement courses, the project may enter a score that exceeds 4.000. Report the score with three decimal places; do not round. (The Web application will not round any scores, but will remove zeros so that, for example, your entry of 4.000 will appear as 4.)		✔
Participation and status in secondary school	33	High School Cumulative Unweighted Grade Point Average (GPA), at end of academic year being reported (2015–16)	HSGPAUnweighted	0.001 to 4.000 (without exceptions) 8.888 = Not applicable, the academic year ended before the participant had completed the first year of high school (for example, student first served as a rising ninth-grader in a project with reporting period beginning in September); or summer bridge student in project with summer start date who graduated from high school before academic year 2015–16 9.999 = Not applicable, prior-year participant 0.000 = Unknown GPA, or grading scale could not be converted to a four-point scale This field captures information on the participant’s unweighted GPA score (0.001 to 4.000); no adaptations may be made for such reasons as completing honors or Advanced Placement courses. If you do not know whether the GPA is weighted or not, enter 0.000. Report the score with three decimal places; do not round. (The Web application will not round any scores, but will remove zeros so that, for example, your entry of 4.000 will appear as 4.)		✔
Participation and status in secondary school	34	High School Graduation Status, at end of academic year being reported 2015–16)	HsGRAD	1 = Currently enrolled in high school 2 = High school dropout 3 = Received regular secondary school diploma 4 = Received high school equivalency credentials (e.g., GED) 5 = Other 6 = Completed 12th grade but failed to meet state or local requirements for graduation 0 = Unknown For definition of regular secondary school diploma, see “Definitions That Apply” in the General Instructions. Once option 3 has been submitted in one year’s APR, the date in field #35 (HsgradDT) must not change in later reporting years.		✔
Participation and status in secondary school	35	Actual Date of High School Graduation (or completion of high school equivalency certificate)	HsgradDT	Format is MM/DD/CCYY, e.g., 05/15/2016 MM = 01 – 12 DD = 01 – 31 CC = 19 – 20 YY = 00 – 99 66/66/6666 = Not applicable, student who completed the 12th grade but did not meet state or local requirements for graduation 99/99/9999 = Not applicable, other circumstances (e.g., high school dropout or still enrolled in high school) 00/00/0000 = Unknown Accuracy is particularly important for this field. Report only graduations and awards of GED that have actually occurred. You do not need to provide the exact day; you may use 15 (midpoint of the month). Once a high school graduation or GED award date has been submitted in one year’s APR, the date must not change in a later reporting year.
Participation and status in secondary school	36	Rigorous Secondary School Program of Study Completed	RigorousStudy	1 = Current or prior-year participant who graduated high school during the school year (2015–16) with a regular secondary school diploma, and completed a rigorous secondary school program of study 2 = Current or prior-year participant who graduated high school during the school year (2015–16) with a regular secondary school diploma, and did not complete a rigorous secondary school program of study 8 = All other participants 0 = Unknown Please see “Definitions That Apply” in the General Instructions.		✔
Participation and status in secondary school	37	Secondary School Retention and Graduation Objective – Numerator, for reporting year	SchoolPersistNum	5 = Not applicable, field #37 no longer used.
Participation and status in secondary school	38	Met High School State Academic Achievement Standard at Proficient Level – Reading/ Language Arts	HSProficientRLA	Participant achieved the proficient level on state high school reading/language arts assessments. 3 = Yes 4 = No 9 = Not applicable, student has not taken the state assessment to determine whether he or she met standard; student took assessment but results are not yet available; no suitable assessment exists; no proficient level for assessment has been established; or student was in an expected high school graduation cohort year prior to 2008. 0 = Unknown Fields #38 and #39 will be used to calculate the PE objective on academic performance as reflected in standardized tests; while this is calculated only for seniors, data should be reported and updated as necessary in each reporting year. If, for example, an 11th-grader passes both assessments at the proficient level in reporting period 2015–16, the project will choose option 1 both in 2015–16 and (unchanged) in 2016–17, reflecting the student’s senior year; the PE calculation for the student will occur in 2016–17. To be counted toward meeting this objective, a current-year senior participant must achieve the proficient level on state high school assessments in both reading/language arts and math. Projects must only use assessments that specifically indicate whether the student achieved at the proficient level.		✔
Participation and status in secondary school	39	Met High School State Academic Achievement Standard at Proficient Level – Math	HSProficientMATH	Participant achieved the proficient level on state high school math assessments. 3 = Yes 4 = No 9 = Not applicable, student has not taken the state assessment to determine whether he or she met standard; student took assessment but results are not yet available; no suitable assessment exists; no proficient level for assessment has been established; or student was in an expected high school graduation cohort year prior to 2008. 0 = Unknown Fields #38 and #39 will be used to calculate the PE objective on academic performance as reflected in standardized tests; while this is calculated only for seniors, data should be reported and updated as necessary in each reporting year. If, for example, an 11th-grader passes both assessments at the proficient level in reporting period 2015–16, the project will choose option 1 both in 2015–16 and (unchanged) in 2016–17, reflecting the student’s senior year; the PE calculation for the student will occur in 2016–17. To be counted toward meeting this objective, a current-year senior participant must achieve the proficient level on state high school assessments in both reading/language arts and math. Projects must use only assessments that specifically indicate whether the student achieved at the proficient level.		✔
Participation and status in secondary school	40	Advanced Placement (AP) or International Baccalaureate (IB) Course Completed	APCourse	Participant completed an Advanced Placement (AP) or International Baccalaureate (IB) course in high school (even if before being served by UB/UBMS or after leaving the program). 1 = Yes 2 = No 8 = Not applicable, participant is enrolled at a school that offers neither AP nor IB coursework 9 = Not applicable, prior participant who graduated high school before the 2012–13 reporting year 0 = Unknown Please provide data, as available, for all current participants and for prior participants who had not graduated before the 2012–13 reporting year. If the participant completed an AP course, select option 1 even if the participant did not take the AP exam or if he or she took the exam but did not earn college credit from the score. If the student completed an IB course, select 1 even if the participant did not take an IB exam or earn the IB diploma. Completion of honors courses should not be considered when selecting an option for this field.		✔
Participation and status in secondary school	41	Dual Enrollment Participation	DualEnrollPart	Student participated in dual enrollment program during high school 1 = Yes, in a program entailing a 5th year of high school 2 = Yes, in a program not entailing a 5th year of high school 3 = No, not in a dual enrollment program 9 = Not applicable, prior participant not served in the 2012–17 grant cycle 0 = Unknown Please refer to the General Instructions for a discussion of reporting students’ participation in dual enrollment programs. Notes: Students in dual enrollment programs must not be reported in fields #52–66 as enrolled in a program of postsecondary education unless they enrolled after high school graduation. Once a student’s participation in a dual enrollment program has been reported, grantees do not need to update field #41 in subsequent years, but instead should simply retain the previous year’s response. Please see General Instructions for details.		✔
Participation and status in secondary school	42	Dual Enrollment: Pre-diploma Credentials or Coursework Completed	DECredentials	1 = Participant completed a certificate through a dual enrollment program 2 = Participant completed an associate degree through a dual enrollment program 3 = Participant never enrolled in dual enrollment program, but completed at least one course undertaken for postsecondary credit 4 = All other participants except those in options 9 and 0 9 = Not applicable, prior participant not served in the 2012–17 grant cycle 0 = Unknown Students in dual enrollment programs must not be reported in fields #52–66 as enrolled in a program of postsecondary education unless they enrolled after high school graduation. Once a project has reported a student’s certificate, associate degree, or course completion in field #42, the grantee does not need to update the field in subsequent years, but instead should simply retain the previous year’s response. Please see General Instructions for details.		✔
Participation and status in secondary school	43	Advanced Math Courses Completed	AdvancedMath	Participant completed two years of math beyond algebra 1 in high school 1 = Yes 2 = No 9 = Not applicable, prior participant graduated high school before the 2012–13 reporting year 0 = Unknown Beyond algebra 1 math courses consist of those that are more advanced than algebra 1 (e.g., geometry, algebra 2, trigonometry, pre-calculus). Please provide data, as available, for all current participants and for prior participants who had not graduated before the 2012–13 reporting year.		✔
Participation and status in secondary school	44	Free Application for Federal Student Aid (FAFSA) completed	FAFSA	1 = Current or prior-year participant who graduated high school or received high school equivalency credentials during the reporting year and who completed the FAFSA . 2 = Current or prior-year participant who graduated high school or received high school equivalency credentials during the reporting year and who did not complete the FAFSA 8 = Not applicable, student did not graduate high school or receive high school equivalency credentials during the reporting year 9 = Not applicable, prior-year participant who graduated high school before the 2012–13 reporting year 0 = Unknown		✔
Participation and status in secondary school	45	Date of Last Project Service	LastSerDT	Format is MM/DD/CCYY, e.g. 03/15/2013 MM = 01 – 12 DD = 01 – 31 CC = 19 – 21 YY = 00 – 99 99/99/9999 = Not applicable, participant is still in the program 00/00/0000 = Unknown Accuracy is particularly important for this field. Report date of last service for all participants no longer being served by submission date of APR. You do not need to provide the exact day; you may use 15 (midpoint of the month). Once date of last project service has been submitted in one year’s APR, the date must not change in a later reporting year. (See General Instructions regarding reentry participants.)
Participation and status in secondary school	46	Reason for Leaving Project	Reason	1 = Need or desire for employment 2 = Moved out of target area 3 = Dropped out of high school 4 = Other extra-curricular activities 5 = Participating in another academic program (not UB or UBMS) 6 = No longer interested in the program 7 = Family responsibilities 8 = Graduated from high school 9 = No longer used 10 = Obtained high school equivalency credential (GED) 11 = Deceased or permanently incapacitated 12 = Dismissed for not meeting program’s academic standards 13 = Dismissed for not meeting program’s conduct standards 14 = Transferred to another UB or UBMS project 20 = Other 99 = Not applicable, participant is still in program 0 = Unknown		✔
Project Services	47	Work Study Position, for reporting year (2015–16)	WorkStd	1 = Yes 2 = No 8 = Not applicable, not offered by project 9 = Not applicable, prior-year participant 0 = Unknown Work study (as the term is used in the Higher Education Act of 1965) means internships and/or employment provided or arranged for by the project for the purpose of exposing participants to careers requiring a postsecondary degree.		✔
Project Services	48	Employment, for reporting year (2015–16)	Employ	1 = Yes, at job arranged by the project 2 = Yes, at job that the student secured without assistance from project 3 = No 9 = Not applicable, prior-year participant 0 = Unknown Employment means jobs of at least 10 hours per week arranged either by the project or by the Upward Bound participant that are separate from the Upward Bound program. In contrast to "work study" positions, these jobs are primarily to allow students to earn some income while participating in the program.		✔
Project Services	49	Cultural Activities, for reporting year (2015–16)	CultAct	1 = Yes 2 = No 8 = Not applicable, not offered by project 9 = Not applicable, prior-year participant 0 = Unknown Please see "Definitions That Apply" in the General Instructions.		✔
Project Services	50	Community Service, for reporting year (2015–16)	CmtySer	1 = Yes 2 = No 8 = Not applicable, not offered by project 9 = Not applicable, prior-year participant 0 = Unknown Please see "Definitions That Apply" in the General Instructions.		✔
Project Services	51	Instruction/tutorial for Students with Limited English Proficiency (LEP), for reporting year (2015–16)	LEPInstruct	1 = Yes 2 = No 8 = Not applicable, not offered by project 9 = Not applicable, prior-year participant 0 = Unknown Please see "Definitions That Apply" in the General Instructions.		✔
Postsecondary education (please see note regarding fields #52–66 at end of Section II)	52	Source of Postsecondary Education Information	SelfTranCD	1 = Official college transcript 2 = Institutional data other than an official transcript 3 = Self-reported by participant 4 = Other third-party verification (e.g., National Student Clearinghouse) 8 = Not applicable, not yet completed high school 9 = Not applicable, completed high school but has not yet enrolled in program of postsecondary education 0 = Unknown Note: For students who received notification from their IHE of acceptance but deferred enrollment until the next academic semester, projects should select option 2.		✔
Postsecondary education (please see note regarding fields #52–66 at end of Section II)	53	Date of First Postsecondary School Enrollment	FirstEnrollDT	Format is MM/DD/CCYY, e.g., 09/15/2016 MM = 01 –12 DD = 01 – 31 CC = 19 – 20 YY = 00 – 99 66/66/6666 = Received notification from IHE of acceptance but deferred enrollment until next academic semester 88/88/8888 = Not applicable, not yet completed high school 99/99/9999 = Not applicable, completed high school but has not yet enrolled in program of postsecondary education 00/00/0000 = Unknown Accuracy is particularly important for this field. You do not need to provide the exact day; you may use 15 (midpoint of the month). Do not use the date of the Summer Bridge program as the first postsecondary school enrollment date if the Bridge program is part of the services offered by the Upward Bound project. Also, a student in a dual enrollment program should not be reported as enrolled in postsecondary education unless he or she enrolls in a postsecondary program after high school graduation. The date of postsecondary enrollment reported in this field should be the date the student enrolled in postsecondary education following graduation from high school or completion of an alternative secondary education program. Once date of first PSE enrollment has been submitted in one year’s APR, the date must not change in a later reporting year.
Postsecondary education (please see note regarding fields #52–66 at end of Section II)	54	Postsecondary Education Enrollment Cohort	PSECohort	2008 (graduated high school in academic year 2007–08 with a regular secondary school diploma and enrolled in postsecondary education by fall 2008) 2009 2010 2011 2012 2013 2014 2015 2016 8888 = Not applicable, not yet completed high school 9999 = Not applicable, does not qualify for a cohort This field is used to establish the cohort of students who will form the denominator for each project’s postsecondary completion objective and for certain performance measures. Once established, a cohort year or a value of 9999 for a participant will not be adjusted in later years. The cohort for each project year includes current participants (i.e., those served during the reporting period) and prior-year participants who graduated high school during the academic year with a regular secondary school diploma and enrolled in postsecondary education by the fall term immediately following the high school graduation date, or who received notification from their IHE of acceptance but deferred enrollment until the next academic semester. For current and prior-year participants who actually graduated from high school in academic year 2015–16, grantees must choose 2016 or 9999, depending on whether the participant qualifies for the 2016 cohort. (See General Instructions regarding participants that do not qualify for a cohort year.) Participants who have not yet completed high school should be coded 8888. For summer bridge participants in June- and July-start projects, you must provide postsecondary enrollment data (HsGRAD #34, HsgradDT #35, FirstEnrollDT #53, and PSECohort #54) in the 2015–16 APR on participants served in 2016 summer bridge to include such students in the 2016 cohort. Once a postsecondary enrollment cohort year or a value of 9999 has been established for a participant and submitted in an APR, it will not change in a later reporting year.
Postsecondary education (please see note regarding fields #52–66 at end of Section II)	55	School Code for Postsecondary Institution First Attended	PSECDFE	B00000 – B99999 E00000 – E99999 G00000 – G99999 000000 – 999999 555555 = Enrolled in a postsecondary institution not found in the Federal School Code Directory 666666 = Not applicable, prior participant whose enrollment in last institution attended was reported in previous grant cycle(s). 888888 = Not applicable, not yet completed high school 999999 = Not applicable, completed high school but has not yet enrolled in program of postsecondary education 000000 = Unknown Provide the six-digit school code for the postsecondary institution the Upward Bound participant first attended. Even if the student began attendance in fall 2016 (i.e., after the end of the 2015–16 reporting period), please provide the code of the institution. The six-digit codes can be obtained from the following Web site: https://fafsa.ed.gov/FAFSA/app/schoolSearch?locale=en_EN Once a grantee has provided a school code for the postsecondary institution the participant first attended, the data must not change in a later reporting year. Note: For students who received notification from their IHE of acceptance but deferred enrollment until the next academic semester, projects should include the school code for the IHE.		✔
Postsecondary education (please see note regarding fields #52–66 at end of Section II)	56	College Status, at beginning of 2016–17 (academic year following year being reported)	PSEGradeLV	1 = Accepted into postsecondary education program but not yet enrolled 2 = First year student in postsecondary education following completion of high school 3 = Postsecondary student continuing beyond first year 4 = Enrolled, completed a program of postsecondary education but continuing in postsecondary 5 = Not enrolled, completed a program of postsecondary education prior to beginning of academic year reported 7 = Prior to beginning of reporting year, left program of postsecondary education without completing it 8 = Not applicable, not yet completed high school 9 = Not applicable, completed high school but has not enrolled in a program of postsecondary education 10 = Other 11 = Postsecondary institution notified participant of acceptance but deferred enrollment until next academic semester 0 = Unknown A student in a dual enrollment program should not be reported as enrolled in postsecondary education unless he or she enrolls in a postsecondary program after high school graduation. If you select option 4 or 5, both of which indicate that the participant completed a program of postsecondary education, you must also complete fields #57 and #58 (for Certificate/diploma completion), fields #59 and #60 (for Associate degree completion), and/or fields #61 and #62 (for Bachelor’s degree completion).		✔
Postsecondary education (please see note regarding fields #52–66 at end of Section II)	57	Certificate/ Diploma Completed	CertificateCD	1 = Yes, completed certificate/diploma for occupational/educational program 2 = No, student pursued another kind of postsecondary credential (not associated with a certificate/diploma program) 3 = Received notification from postsecondary institution of acceptance but deferred enrollment until next academic semester 6 = Enrolled in, but not completed certificate/diploma program 7 = Left a certificate/diploma program without completing it 8 = Not applicable, not yet completed high school 9 = Not applicable, completed high school but has not yet enrolled in a program of postsecondary education 0 = Unknown If student has been in a certificate program, choose 1, 6, 7, or 0.		✔
Postsecondary education (please see note regarding fields #52–66 at end of Section II)	58	Date of Certificate/ Diploma	CertificateDT	Format is MM/DD/CCYY, e.g., 06/15/2016 MM = 01 –12 DD = 01 – 31 CC = 19 – 20 YY = 00 – 99 22/22/2222 = Not applicable, student pursued another kind of postsecondary credential (not associated with a certificate/diploma program) 33/33/3333 = Not applicable, received notification from postsecondary institution of acceptance but deferred enrollment until next academic semester 66/66/6666 = Not applicable, still enrolled in certificate/diploma program 77/77/7777 = Not applicable, left certificate/diploma program without completing it 88/88/8888 = Not applicable, not yet completed high school 99/99/9999 = Not applicable, completed high school but has not yet enrolled in program of postsecondary education 00/00/0000 = Unknown Accuracy is particularly important for this field. If participant has earned more than one certificate or diploma, report the date that the first certificate or diploma was completed. You do not need to provide the exact day; you may use 15 (midpoint of the month). Once date of certificate/diploma has been submitted in one year’s APR, the date must not change in a later reporting year.
Postsecondary education (please see note regarding fields #52–66 at end of Section II)	59	Associate Degree Attained	AssocDegreeCD	1 = Yes, attained associate degree 2 = No, student pursued another kind of postsecondary credential (not associated with an associate degree program) 3 = Received notification from postsecondary institution of acceptance but deferred enrollment until next academic semester 5 = Transferred to four-year institution without completing an associate degree 6 = Enrolled in, but not completed associate degree program 7 = Left associate degree program without completing it; did not transfer to a four-year institution 8 = Not applicable, not yet completed high school 9 = Not applicable, completed high school but has not yet enrolled in a program of postsecondary education 0 = Unknown If student has been in an associate degree program, choose 1, 5, 6, 7, or 0.		✔
Postsecondary education (please see note regarding fields #52–66 at end of Section II)	60	Date of Associate Degree	AssocDegreeDT	Format is MM/DD/CCYY, e.g., 06/15/2016 MM = 01 –12 DD = 01 – 31 CC = 19 – 20 YY = 00 – 99 22/22/2222 = Not applicable, student pursued another kind of postsecondary credential (not associated with an associate degree program) 33/33/3333 = Not applicable, received notification from postsecondary institution of acceptance but deferred enrollment until next academic semester 55/55/5555 = Not applicable, transferred to four-year institution without completing an associate degree 66/66/6666 = Not applicable, still enrolled in associate degree program 77/77/7777 = Not applicable, left associate degree program without completing it 88/88/8888 = Not applicable, not yet completed high school 99/99/9999 = Not applicable, completed high school but has not yet enrolled in program of postsecondary education 00/00/0000 = Unknown Accuracy is particularly important for this field. If participant has earned more than one associate degree, report the date that the first associate degree was completed. You do not need to provide the exact day; you may use 15 (midpoint of the month).Once date of associate degree has been submitted in one year’s APR, the date must not change in a later reporting year.
Postsecondary education (please see note regarding fields #52–66 at end of Section II)	61	Bachelor’s Degree Attained	BachDegreeCD	1 = Yes, attained bachelor’s degree 2 = No, student pursued another kind of postsecondary credential (not associated with bachelor’s degree program) 3 = Received notification from postsecondary institution of acceptance but deferred enrollment until next academic semester 6 = Enrolled in, but not completed bachelor’s degree program 7 = Left bachelor’s degree program without completing it 8 = Not applicable, not yet completed high school 9 = Not applicable, completed high school but has not yet enrolled in a program of postsecondary education 0 = Unknown If student has been in a bachelor’s degree program, choose 1, 6, 7, or 0. See “Definitions That Apply” regarding dual degree programs.		✔
Postsecondary education (please see note regarding fields #52–66 at end of Section II)	62	Date of Bachelor’s Degree	BachDegreeDT	Format is MM/DD/CCYY, e.g., 06/15/2016 MM = 01 –12 DD = 01 – 31 CC = 19 – 20 YY = 00 – 99 22/22/2222 = Not applicable, student pursued another kind of postsecondary credential (not associated with bachelor’s degree program) 33/33/3333 = Not applicable, received notification from postsecondary institution of acceptance but deferred enrollment until next academic semester 66/66/6666 = Not applicable, still enrolled in bachelor’s degree program 77/77/7777 = Not applicable, left bachelor’s degree program without completing it 88/88/8888 = Not applicable, not yet completed high school 99/99/9999 = Not applicable, completed high school but has not yet enrolled in program of postsecondary education 00/00/0000 = Unknown Accuracy is particularly important for this field. If participant has earned more than one bachelor’s degree, report the date that the first bachelor’s degree was completed. You do not need to provide the exact day; you may use 15 (midpoint of the month).Once date of bachelor’s degree has been submitted in one year’s APR, the date must not change in a later reporting year.
Postsecondary education (please see note regarding fields #52–66 at end of Section II) Please read the instructions carefully before completing fields #63–66.	63	Postsecondary Enrollment Objective--Numerator, for reporting year (2015–16)	PSEEnrollObjNum	1 = Current or prior-year participant who graduated high school during school year 2015–16 with a regular secondary school diploma and who enrolled in postsecondary education by fall term 2016 2 = Current or prior-year participant who graduated high school during school year 2015–16 with a regular secondary school diploma and who received notification by fall 2016 from IHE of acceptance but deferred enrollment until next academic semester 3 = Current or prior-year participants, not reported in 1 or 2 above, who graduated high school with a regular secondary school diploma during school year 2015–16 8 = Not applicable, all other current or prior-year participants 0 = Unknown Note: For participants who graduated high school during school year 2015–16 with a regular secondary school diploma, select option 1, 2, or 3; for all other participants (that is, those not graduating with a regular high school diploma in school year 2015–16), select 8 or 0.		✔
Postsecondary education (please see note regarding fields #52–66 at end of Section II) Please read the instructions carefully before completing fields #63–66.	64	Postsecondary Remediation	PSRemediation	1 = No remediation: In 2016 postsecondary education enrollment cohort (see field #54) and neither received college-level math or English remediation in fall 2016 semester of postsecondary education nor was required to receive it in academic year 2016–17 2 = Yes, received remediation: In 2016 postsecondary education enrollment cohort (see field #54) and received college-level math or English remediation in fall 2016 semester of postsecondary education, or was required to receive it in academic year 2016–17 9 = Not applicable, participant not in 2016 postsecondary education enrollment cohort 0 = Unknown Regarding the term “remediation,” please see “Definitions That Apply” in the General Instructions.		✔
Postsecondary education (please see note regarding fields #52–66 at end of Section II) Please read the instructions carefully before completing fields #63–66.	65	Postsecondary Completion Objective – Numerator, for reporting year (2015–16)	PSCompleteNum	1 = Yes, in 2010 postsecondary education enrollment cohort (see field #54) and attained either associate or bachelor’s degree within six years following high school graduation (i.e., by August 31, 2016). 2 = No, in 2010 postsecondary education enrollment cohort (see field #54) and attained neither associate nor bachelor’s degree within six years following high school graduation (i.e., by August 31, 2016). 9 = Not applicable, participant not in 2010 postsecondary education enrollment cohort 0 = Unknown For participants in the 2010 PSE enrollment cohort, select option 1 if the participant completed either an associate or bachelor’s degree by the end of the 2015–16 academic year; otherwise, select option 2 (did not meet objective) or 0 (unknown).		✔
Postsecondary education (please see note regarding fields #52–66 at end of Section II) Please read the instructions carefully before completing fields #63–66.	66	Postsecondary STEM Degree (UBMS only)	STEMDegree	UBMS participant in postsecondary education enrollment cohort 2010 (see field #54) who earned a postsecondary degree in a STEM field by August 31, 2016. 1 = Yes, in a field in the “hard” sciences 2 = Yes, in psychology or social sciences 3 = No, UBMS participant in 2010 cohort who did not earn a postsecondary degree in a STEM field by 8/31/2016 8 = Not applicable, participant in regular UB program 9 = Not applicable, UBMS participant not in 2010 cohort 0 = Unknown For UBMS participants in the 2010 postsecondary education enrollment cohort who have earned a postsecondary degree, select option 1 or 2 if student’s degree is in one of the STEM fields as listed in the General Instructions.		✔
Additional participant information	67	Participant’s Name Change (Optional)	FullNameChange	If a participant changed his or her name (for example, due to marriage), and if the project wishes to record this information in the APR to help track the student, the project may enter the participant’s changed full name (i.e., first and last name) in field #67. Note that the first and last names provided in fields #5 and 6 (LastNM and FirstNM) remain identifiers that the Department will use to track the student; thus fields #5 and 6 must not change from year to year. Names entered in field #67 may be in a variety of formats, e.g., John Doe, John D. Doe, Jane Smith-Doe, Jane Smith Doe, John Doe II, John Doe, Jr. Moreover, you will be able to update this field in subsequent reporting periods. If the student has not changed his or her name, the project need not complete field #67.		✔

Note to Data Collector: When you collect this information from students or parents, please make sure that you inform them why they are being asked to provide Social Security numbers. Please see Privacy Act statement below.

Important note regarding postsecondary fields (#52–66): In these fields, enter "7" or a series of "7s," where requested, for students who have left a program of postsecondary education without completing it. Enter “8” or a series of “8s” as specified for participants who have not yet completed a program of secondary education. Students in dual enrollment programs should not be reported as enrolled in postsecondary education unless they enroll in a postsecondary program after their high school graduation. Enter “9” or a series of “9s” for high school graduates who have not yet enrolled in a program of postsecondary education. Remember that data in these fields should reflect information available to the project as of the date on which the APR is submitted. A participant is considered enrolled if he or she has completed registration requirements (excluding payment of tuition and fees) at the institution he or she is attending. Projects should report all participants’ postsecondary data, even if a participant does not qualify for a cohort.

Privacy Act

In accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U. S.C. 552A), you are hereby notified that the Department of Education is authorized to collect information to implement the Upward Bound program under Title IV of the Higher Education Act of 1965, as amended (Pub. Law 102-325, sec. 402A and 402C). In accordance with this authority, the Department receives and maintains personal information on participants in the Upward Bound program. The principal purpose for collecting this information is to administer the program, including tracking and evaluating participants’ academic progress. Providing the information on this form, including a Social Security number (SSN), is voluntary; failure to disclose a SSN will not result in denial of any right, benefit, or privilege to which the participant is entitled. The information that is collected on this form will be retained in the program files and may be released to other Department officials in the performance of official duties.

[This document is dated November 2016.]

December 2016