"Intake Form - Download as DOC"
1 Intake and Service Assessment Program Expectations Student Support Services is an academic retention program for a select group of 160 students annually. TRIO SSS expect students to commit to working with the program for at least one year and encourage active participation throughout their matriculation at UT. In addition, we expect the following: A. Students will complete the Intake, including the Service Request Form and Writing Sample. B. New students will meet with their academic counselor a minimum of four times during each semester and actively participate in other services, such as, workshops or tutoring. C. Continuing students will meet with their academic counselor at least four times a year. D. Students will complete a program evaluation at the end of each semester of service. E. Students will follow the recommendations of the staff. Our services are targeted to your individual needs. Our services are comprehensive ranging from skills-based instruction and tutoring to mentoring/leadership skills to ombudsman services and graduation guidance. SSS offers to you the ability to manage your skills and interests to acquire additional campus and community opportunities and to take advantage of resources which meet your career goals. As a participant in the TRIO Student Support Services program at UT, you have the right to: Receive prompt and courteous service from all staff members Receive tutoring assistance in college courses and study skills Receive strategic academic advising and counseling Receive career and personal counseling and referrals Participate in cultural and leadership activities Receive assistance with admission to graduate and professional programs Receive financial and economic literacy and financial planning information Receive information on federal student financial aid programs and assistance in completing financial aid applications Have access to student mentors 2 Student Support Services Intake Packet Part I: Intake Demographic Data Name: Local Address: Street, Apt. #, City Zip + 4 Local Phone: Alt Phone: Month/Year First Attend College: Yr/Sem entered UT? Family Contact Name Address and Phone High School Attended: City/State of High School: Year of High School Graduation/GED: Educational Assistance 1. Have you declared a major? Y OR N 2. In which major at UT are you enrolled or planning to enroll? ____________________ Is it considered a highly competitive major? Y OR N Advisor Name: 3. Will you need tutoring assistance? (If yes, indicate area of need) Y OR N a. (Fill-In) Math _________________ Science _____________________ (circle) Economics Psychology Business Government Sociology Chemistry History English Composition b. Other: ______________________ Academic Eligibility 4. Have you ever been in another TRIO program? (SSS, UB, EOC, TS) Y OR N 5. Have you previously attended any other college? Y OR N a. If yes, name of college: 6. Is your cumulative GPA below a 2.0? Y OR N a. Was your previous semester GPA below a 2.0? Y OR N 7. Are you on Academic Probation, Suspension or Warning? Y OR N 8. Have you been placed in a non-credit course? Y OR N 9. Were you referred to SSS by an academic advisor or instructor? Y OR N 10. Have you been granted special or conditional admission to attend UT? Y OR N 3 Other Eligibility 11. Indicate from the list below information that pertains to you. Please mark yes or no for each item. a. _____ Disability b. _____ Low Income c. _____ Nontraditional Employment and / or training program d. _____ Single Parent with minor child / Single Pregnant Woman e. _____ Displaced Homemaker f. _____ Limited English Proficiency (English as a second language) 12. Are you employed? Full-time (40 hours or more) ____ or part-time ____? Y OR N Early Progress Reports (Notification) Student Support Services (SSS) program is federally funded by the US Department of Education. At The University of Toledo, one hundred and sixty students participate in year- round academic, tutorial, cultural and educational activities. The purpose of TRIO is to increase the number of students who attend and graduate from college. The SSS staff monitors students throughout the year. In an effort to assist you in achieving and maintaining academic success, we will solicit course specific information from your instructors. The Release of Information Statement on page 4 gives us written permission to request this information and review it with you. To assure that all Student Support Services participants are making satisfactory academic progress, we will ask your instructors’ assistance in providing the information requested on SSS Progress Reports. The Progress Report will assist in the documentation of your academic progress to avoid failure and aid successful students. The information will be shared with you and used to determine if additional help is needed. The SSS Progress Report may be submitted twice each semester you are enrolled and more often at your request. As an SSS participant acknowledge that I am aware that for each semester that I am enrolled at The University of Toledo the SSS program will submit Progress Reports to my instructors. I further acknowledge that this is a condition of my involvement in the SSS program and is the same for all students. 4 Release Of Information Statement I, _______________________________, authorize Student Support Services (SSS) to gather information concerning my academic progress (standardized test scores, grade point average, earned credits, transcripts) and financial aid information prior to my participation and throughout my involvement in SSS. I understand that this information is used to assist in the determination of my eligibility for the SSS and it will be strictly confidential. I am aware that my eligibility, participation and financial aid status will be reported to the U.S. Department of Education in accordance with the grant funding regulations. I certify that the information provided on this application is true and complete to the best of my knowledge. I also agree to provide documentation upon request to verify the information reported. I am aware that the personal information that is provided to the Student Support Services Program will be protected under the Family Education Rights Privacy Act of 1974. No one will have access to the information unless they work with or for the SSS Program, or are specifically authorized by me to see the information. Upon formal acceptance into the program, I grant permission for program representative to have access to my academic and financial official records in order for SSS staff to assist me. Additionally, in the course of my involvement in the SSS program, SSS staff may consult with various University of Toledo offices and programs to secure and share the necessary information pertinent to my participation in the program and overall collegiate success. Signature Date: _______________ Parent Signature (for applicants under the age of 18) 5 Part II: Needs Analysis NAME Academic Year Skills: Read the following statements carefully. If the statement is true about you, circle “True.” If the statement is false or mostly false about you, circle “False.” True False I often have to read class material several times before I understand it. True False I have the next class’s reading assignment completed before that class. True False I normally wait until an exam is scheduled before reading textbooks or reviewing lectures. True False My lecture notes prepare me adequately for exams. True False I take notes when I read class material. True False The notes I take on my reading prepare me adequately for exams. True False I have difficulty preparing for exams because I have trouble predicting what will be on them. True False I generally depend on last minute cramming (the day before exam and/or the day of exam). A. I believe that I need help to improve in the following area (s): _____Math Skills _____Writing Skills _____Reading Skills _____Study Skills B. I believe that my academic strengths in this area will make me an ideal tutor: _____Math _____Writing Skills _____Research Skills _____Sciences Time Management: Last semester, where did you do the majority of your studying? Please indicate the approximate number of hours per week you spent on each of the following: Attending Class Studying (reading, writing papers, lab reports, etc) during the week (M-F) Studying on the weekends (Saturday and Sunday) Working at a paid job Social or extra-curricular activities Other major commitments (please explain) Did you have trouble finding enough time for studying? ____Yes ____No Did you work with a student tutor? Yes No If so, how many times did you meet with your tutor? Did you attend study or test review sessions? ____Yes ____No How often did you consult with your professors outside of class? _____Regularly _____ Occasionally _____Seldom _____Never 6 Attendance Did you attend classes regularly last semester? _____Yes _____No How many classes did you miss in each course last semester? Courses Classes Missed What did you do to make up for missed work in classes? Copied other students’ notes/materials Consulted with the professor Nothing Other (please specify) Health And Personal Issues Was there any period during the past semester when you were sick for more than a day or two? _____No _____Yes, I was sick for a total of days during the semester. If yes, did you see the health center or a physician? _____Yes _____No Identify any particular personal problems during the semester that made it difficult for you to concentrate on your academic work. How long did the problem(s) last? Has it been resolved? _____Yes _____No _____Partly Living Arrangements: Think about your living arrangements for last semester. Were your living arrangements conducive to your studying or were there major distractions where you lived? _____My living arrangements were not an obstacle to my studying. _____Sometimes my living arrangements were a major obstacle to my studying. _____My living arrangements were consistently a major obstacle to my studying. What steps do you plan to take this semester to improve your living arrangements, if they were problematic? Curriculum Please read each of the following statements and check any that are true of you. If there are blanks for any of the statements you check, please complete them. _____I have definitely decided on the following major:________________________ _____I am in upper level courses in my major and could mentor an underclassman in the same major:________________________ _____I am undecided between two or more majors. They are: ________________ _____I am totally undecided about what major I should choose. _____I am aware of leadership opportunities on campus. _____I am not involved in any thing other than my class work. 7 If there are major requirements that are of particular concern for you, please list them below. What course or courses have you liked best at UT? Why? What course or courses have you liked least at UT? Why? Please list below all courses in which you have earned a D or F. Check whether you feel prepared to repeat those courses. Course Grade Willing to Repeat Willing to Repeat at Do Not Want To Next Semester a Later Time Repeat Leadership Experiences Choose One: Strongly Agree- SA My leadership experiences at The University of Toledo this Agree – A year... Disagree – D Strongly Disagree – SD 1. Gave me many opportunities to improve aspects of SA A D SD my leadership skills 2. Provided me with knowledge or information that is SA A D SD very useful to me in my major and my leadership development SA A D SD 3. Were coherently related to each other SA A D SD 4. Did not offer enough hands-on/interactive training 5. Provided me with useful feedback about my SA A D SD leadership skills 6. Made me pay closer attention to particular things I SA A D SD was doing in my leadership and classroom work 7. Led me to seek out additional information from SA A D SD another student leader, faculty/staff member, or some other source 8. Led me to think about an aspect of my leadership skill SA A D SD and personal development in a new way 9. Led me to try new things in my leadership roles or SA A D SD classroom work 8 Leadership Skills 1. If you make a decision and someone in 5. When faced with a problem you cannot the group has a different idea, you; resolve, you; a. Explain your decision a. Avoid the problem b. Listen for the explanation of the b. Seek help from others other idea c. Give the task of resolving the c. Ignore the idea problem to someone else 2. If someone makes you realize you made d. Ignore the problem an error in a decision you made, you; 6. If you see someone with a problem you, a. Deny making the decision a. Enjoy watching them resolve the b. Admit to the error problem c. Pay the person to shut up b. Resolve the problem for them 3. If you get into an argument with c. Give hints or tips in resolving the someone, you; problem a. Tell other people that this person 7. To you responsibilities are; is too stubborn to talk to a. A burden b. Try to resolve the situation as b. Part of life soon as possible c. A challenge c. Wait until this person cools down 8. What is the main driving force in your d. Pursue the argument until the life? person gives up a. Money 4. How much trust do you feel people have b. Principles in you? c. Ethics a. Some d. Fame b. None c. Enough d. A lot 9 Part II: Writing Sample Please respond to one or two of the following prompts (You may use additional paper) 1. Please write a paragraph or two about the reasons you believe you have experienced academic difficulty. 2. Please write a paragraph or two about your leadership experiences at The University of Toledo. 3. Please write a paragraph or two about your overall learning experiences and interaction with faculty and staff at UT. 10 11 Student Contract Congratulations and welcome to Student Support Services. As a program participant we ask that you make a commitment to yourself and SSS so you may fully benefit from the services SSS has to offer. Our staff will work closely with you to provide comprehensive services and events as resources allow. As a participating student; you will be responsible for the following: Attend all scheduled appointments or notify Participate in an exit interview when our office if you need to reschedule you graduate and/or transfer or ………………………………..……………….On-going should you decide to leave UT. …..…………………………………………Once Work with SSS staff to develop and All Student Support Services implement a plan to meet your post- participants must inform their SSS secondary education goals. academic advisor of any change in ………………..………………………On-going their class schedules. This allows for effective monitoring of academic Attend/participate/complete the Financial progress and minimizes costly errors Literacy Workshop either online or in that could jeopardize graduation. person. …..…………………………………Once Attend one SSS sponsored event (i.e. campus visit, cultural event, or I understand the program expectations and workshop)……………………..….……….Annually accept my responsibilities as a participating student in Student Support Services. Participate in Supplemental Instruction and/or tutoring in math & science if required I also agree to contact the SSS office with any by your SSS advisor changes in my educational goals if I should ……………………..….……………………..As needed move after I exit the program. I understand that the SSS staff may contact me periodically Attend an advising session at the beginning after I have exited the program to follow up and ending of each semester on my progress towards my educational …………………..……………………………On-going goals. _______________________________ Inform us of changes in your address, e-mail _ or phone number Student Signature Date ….……………………………………………On-going _____________________________________ __ Staff Signature Date Complete an evaluation of our program.………………………...Annually 12 13 Part VI: Service Request Form - Intake Name:_______________________ Phone: _______________ Email: ___________________ requests/needs tutoring in the following subject(s): Subject Course Number and Name Would like to attend the following one-on-one workshop(s): ____ “Applying to Graduate School” ____ “Developing Successful Math Skills” ____ “Overcoming Test Anxiety” ____ “How to Listen and Take Good Notes” ____ “Money Management” ____ “Deciphering Your Text” ____ “Choosing a Major” ____ “Time Management” ____ ”Coping with Failure” ____ “Test Taking Techniques” STUDENT SIGNATURE DATE Original is filed under Intake. A copy is forwarded to the Educational Specialist. Office Use Only: Contact Date Staff Member Result 14 Financial Aid Check Sheet As of July 1, 2011 there are new regulations for federal grants and loans. The Student Support Services wants to ensure that all participants are aware of the new regulations and how those changes will impact their studies at The University of Toledo. Federal student aid is financial assistance provided to students by the federal government. The Office of Student Financial Aid notifies each students with an Award Notification detailing the financial aid package which includes federal student aid in the form of grants, loans, and/or work-study program. That information can be found in your Web for Students. Your financial aid is also subject to change based on error, omissions, receipt of additional aid resources, or changes in your eligibility. Answer the following questions with yes or no Are you receiving financial aid? If not, you can skip all the questions on this page. Are you currently enrolled fulltime? (12 or more hours) Do you understand that if you enroll for less than half time hours in a semester, Federal Pell Grant awards will be reduced proportionately? Do you understand that if you do not attend all of the classes for which you have registered, you may be required to repay all or a portion of the aid you received? Do you understand that you may use awards listed on the Award Notification only for educational expenses incurred at UT. Do you understand that you may receive aid in excess of your tuition in the form of a refund and if you fail to attend your classes or drop your credit hours, you may be required to return the refund? Are you aware that that withdrawing from classes can affect your federal financial aid Are you aware that if you do not maintain satisfactory academic progress, you can receive a financial aid warning? Failing to be in compliance by end of the following semester, can result in the loss of financial aid eligibility. Are you aware that if you enroll for a semester and receive federal aid but earned a 0.0 GPA you will have your federal aid immediately revoked for subsequent semesters? Are there any financial aid questions that you wish to discuss with your SSS advisor ? Signature of SSS Advisor - Date 15