Environmental Health Sciences Summer Institute by qyd44618

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									                         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 mhenderson@mdanderson.org.




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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