UMASSLOGOOutreachProrams
1.
Personal Information
Name
Home Address
City
State
Postal Code
Telephone
Fax
Email
Date of Birth
Gender
Citizenship Status
2.
Education
High School
High School City
High School State
High School Graduation Year
3.
Did you attend College?
4.
if you did go to College, please enter your College Info, if you would.
College/University
City
State
Undergraduate Degree Date (MM/YY)
Major
Minor
5.
Please provide your year of participation in each of these UMMS Programs. Leave the field blank for any program in which you did not participate. Some of you should indicate more than one date here. (Please enter only digits for the year)
High School Health Careers Program
Summer Enrichment Program
NIH Summer Research Fellowship Program
Summer Science Camp
Health Science Academy (first year)
Collaborative Open House
Project SCOPE
Post Baccalaureate Program
Worcester Pipeline Collaborative Laboratory
Regional Science Research Center Laboratory
Women in Science
National Youth Leadership Program
List languages you speak here:
6.
If participating did help, please explain how participation in this/these progam(s) helped you in your career path? (max characters allowed are 1,000)
7.
Did participation in this/these program(s) help you in your career path?
What are you doing now? (100 characters max)
8.
Has any of your work been published? If so, in what publications? (200 characters max)
Race
Enthinicity

Where Are You Now?

Please complete this on-line survey "Where are you now?" so that we can boast about the accomplishments of ALL the UMMS Outreach Programs.

Instructions:

Be sure to answer all questions. 

Please include Country/City/Area Code on all Telephone numbers. These numbers are not being validated for you due to the possible variations in world-wide formats. Preferred format for US numbers is with spacing between number groups, no punctuation. (e.g. 508 856 8989)

Demographics

9.
Do you consider yourself economically disadvantaged?
10.
Would you be a first generation College graduate?
What is/was your career choice and what are you doing now? (Research, Health Professions, teaching, other).
 
Please use these select boxes to indicate how you ranked your top 3 career choices when you participated in our outreach programs, and in which of these work areas you would categorize your current position. Note that all four choices are required.
11.
Now - Current Career Choice
12.Then - First Career Choice
13.Then - Second Career Choice
14.Then - Third Career Choice
This is an official Page of the University of Massachusetts Worcester Campus
School Services - 55 Lake Avenue North, Worcester, Massachusetts,  01655
Questions or Comments? Email: Karen Zirpola Phone: 508-856-4400