The University of Texas M.D. Anderson Cancer Center, Science Park Research Division, Smithville, TX ARRA SURP Questionnaire Support of this program comes from the National Institute of Environmental Health Sciences (Grant No. ES07784). Please complete the information below. The data collected will be used to provide information to the funder(s) to ensure future support for this and other similar programs. This information is kept confidential and only reported in aggregate. Thank you. Please email to the completed questionnaire to Mary Henderson at email@example.com. 1.STUDENT INFORMATION: YOUR NAME: PROGRAM: Summer High School Research Program YOUR E-MAIL ADDRESS: YEAR PARTICIPATED IN PROGRAM: PARENT E-MAIL ADDRESS: STUDENT PHONE #: PARENT PHONE #: 2.ETHNIC BACKGROUND: African American Asian Caucasian Hispanic Pacific Islander Native American Other (please specify): ___________________________ 3.Are you currently a student? YES NO Undergraduate Graduate Professional Other/Specify: _____________________ a. Date of graduation: Major: (Past or Expected) b. School Name: State: 4.Please indicate which degree or profession you are currently pursuing. Please check the appropriate box(es). Undergraduate Science Graduate Non-Science Graduate Professional School Career (major) School School Biological Sciences Bio-Medical Sciences Law Medical School Science/Health Physical Sciences Physical Sciences Humanities Other (Language/Literature) MD/PhD MD DO Nursing Engineering Social Science Veterinary School Briefly describe: Teaching Other Business Dental School Describe: ____________ School of Public Engineering Other Health (MPH, DrPh, PhD) Other Describe: ____________ College of Pharmacy Describe ___________ Thank you for your time! All information collected will be used for programmatic purposes only. Please provide short answers about the SURP Program at Science Park Research Division 5.Why did you want to participate in the Summer Undergraduate Research Program at Science Park? 6.What were your educational and career goals prior to entering the program? 7.Did our program assist you in meeting these goals? a. A lot Some A moderate amount A little None b. If so, please provide some details about how the Summer Research Program help you acquire the knowledge and skills necessary to advance your educational and career goals? 8.Have you participated in other summer research or internship programs before or since your time at Science Park? a. Yes No If yes, b. Before After c. If, yes, please describe which aspects, if any, of the summer program at Science Park built on prior research experiences and which aspects represented a new experience for you. 9.Have your educational and/or professional goals changed as a result of your Summer Research Experience at Science Park? a. Yes No b. If they have changed, please tell us how. Thank you for your time! All information collected will be used for programmatic purposes only. time! All information collected w ill be used for programmatic purposes only .
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