First Name Last Name Birthdate Month... January February March April May June July August September October November December Day... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year... 2015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955

School Email

Personal Email - One that you will always have regardless of where you study or work Cell Phone - Make sure it is one where we can always reach you
- -

Address City State US State/Territory... Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Micronesia Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip

Address City State US State/Territory... Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Micronesia Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip

Name of School City
US State/Territory US State/Territory... Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Micronesia Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Class Level Level... Freshman Sophomore Junior Senior Major

Do you have current or prior work experience? It may be paid or volunteer. Please include ONLY non-scientific work.
Yes
No

Please provide the following information. Click "Add another experience" to add up to 4 experiences.


Employer Dates (MM/YYYY-MM/YYYY) Job Title Job Responsibilities Average Hours/Week Average Hours/Week... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 More than 40
Add another experience
Employer Dates (MM/YYYY-MM/YYYY) Job Title Job Responsibilities Average Hours/Week Average Hours/Week... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 More than 40
Add another experience
Employer Dates (MM/YYYY-MM/YYYY) Job Title Job Responsibilities Average Hours/Week Average Hours/Week... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 More than 40
Add another experience
Employer Dates (MM/YYYY-MM/YYYY) Job Title Job Responsibilities Average Hours/Week Average Hours/Week... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 More than 40

Have you participated in any programs or activities that focus on science, technology, engineering, and mathematics (STEM)? These may include MESA, AVID, Science Fairs,
Yes
No

Please provide the following information. Click "Add another experience" to add up to 4 experiences.


Name of Program/Activity Dates (MM/YYYY-MM/YYYY) Description of Participation
Add another experience
Name of Program/Activity Dates (MM/YYYY-MM/YYYY) Description of Participation
Add another experience
Name of Program/Activity Dates (MM/YYYY-MM/YYYY) Description of Participation
Add another experience
Name of Program/Activity Dates (MM/YYYY-MM/YYYY) Description of Participation

Do you know any computer programming languages, such as Python, R, SAS, Java, C++, or Matlab?
Yes
No

Please list below the names of the programming languages (i.e., Python, R, SAS, Java, C++, Matlab) you know and your level of expertise for each one.

Have you participated in undergraduate research?
Yes
No

Please provide the following information. You may list up to 4 research experiences. If you participated in a formal program, please include the program name, otherwise, write N/A for "Program Name".


Program Name Dates (MM/DD/YYYY-MM/DD/YYYY) Institution/Company Faculty/Supervisor
Add another experience
Program Name Dates (MM/DD/YYYY-MM/DD/YYYY) Institution/Company Faculty/Supervisor
Add another experience
Program Name Dates (MM/DD/YYYY-MM/DD/YYYY) Institution/Company Faculty/Supervisor
Add another experience
Program Name Dates (MM/DD/YYYY-MM/DD/YYYY) Institution/Company Faculty/Supervisor

The ACTION Institute hosts summer internship opportunities at the universities listed below. Please select which one(s) you would be interested in for your experience. You may select as many as you like. Selecting more universities may increase the chances you are selected, but you need to be willing and able to go to any university you select.
Georgia Tech, Atlanta, GA
Norfolk State, Norfolk, VA
Purdue University, West Lafayette, Indiana
Rutgers, Piscataway, NJ
UC Berkeley, Berkeley, CA
UC Santa Barbara, Santa Barbara, CA
University of Chicago, Chicago, IL
University of Illinois, Chicago, IL
University of Illinois, Urbana-Champaign, IL
University of Virginia, Charlottesville, VA
University of Washington, Seattle, WA

How did you hear about ACTION?
Club or Organization
Email
From a recruitment presentation
From my professor
Peers
Poster on campus
Social Media
Other:

Continued funding for our programs depends on our ability to provide complete and accurate demographic information for reporting purposes to funding agencies. Your name will not be associated with your responses when reporting this information externally.

Which of the following represents your status in the US?
I am a US citizen
I am a US permanent resident
I am an international student
None of the above

What is your gender identity?
Woman
Man
I identify as:
Decline to state

Are you of Hispanic/Latinx origin?
Yes
No
Unknown
Decline to state

Which of the following best describes your race? You may hover over each term for a definition. Select all that apply. For example, if you are of Hispanic/Latinx origin, you may be a mix of American Indian/Alaska Native as well as Caucasian. If you are not of Hispanic/Latinx origin, you may still be a mix of American Indian/Alaska Native as well as Caucasian. You may select "Unknown" if your race is unknown to you.

American Indian/Alaska Native Includes all indigenous people of North, Central, and South America

Asian Includes all indigenous people of East Asia, Southeast Asia, and the Indian subcontinent

Black Includes all indigenous people of Africa

Hawaiian/Pacific Islander Includes all indigenous people of Pacific Islands, including Hawaii, Guam, Fiji, Philippines, Tonga, and Samoa

Caucasian Includes all indigenous people of Europe and Middle Eastern countries, including Spain, Italy, and Portugal

Unknown Your ancestry is unknown to you

Decline to state

What language(s) did you grow up speaking in your home?
English
Spanish
Other (please state):
Decline to state

Do you have any disabilities, defined as a physical or mental impairment that substantially limits one or more major life activities?
Yes
No
Decline to state

Are you a veteran of the US Armed Forces?
Yes
No
Decline to state

Which of the following programs have you ever participated in?
Advancement via Individual Determination (AVID)
California Alliance for Minority Participation (CAMP)
Educational Opportunity Program (EOP)
McNair Scholars Program
Mathematics, Engineering, and Science Achievement (MESA)
I have not participated in any of the above programs.
Decline to state

Do you qualify for a free or reduced lunch?
Yes
No
Unknown
Decline to state

Which of the following apply to you?
I qualify for federal disadvantaged assistance
I am eligible for the Pell Grant
My EFC (expected family contribution) is below $5,000
My family household income is at or below the Federal poverty threshold for my household size (click here to view Federal tables)
None of these apply
Decline to state

Are you from a single parent home?
Yes
No
Decline to state

Have you ever been in the foster care system?
Yes
No
Decline to state

Please provide the education level of the parents/guardians who you have lived with. You can enter up to 4 by clicking "Add another parent/guardian".

1. Education Level of Parent/Guardian #1 Please select... Did not finish high school High school graduate Attended college, but no degree Associate's Degree Bachelor's Degree Master's Degree Professional degree or credential Doctoral Degree (PhD) I don't know Decline to state
Add another parent/guardian
Education Level of Parent/Guardian #2 Please select... Did not finish high school High school graduate Attended college, but no degree Associate's Degree Bachelor's Degree Master's Degree Professional degree or credential Doctoral Degree (PhD) I don't know Decline to state
Add another parent/guardian
Education Level of Parent/Guardian #3 Please select... Did not finish high school High school graduate Attended college, but no degree Associate's Degree Bachelor's Degree Master's Degree Professional degree or credential Doctoral Degree (PhD) I don't know Decline to state
Add another parent/guardian
Education Level of Parent/Guardian #4 Please select... Did not finish high school High school graduate Attended college, but no degree Associate's Degree Bachelor's Degree Master's Degree Professional degree or credential Doctoral Degree (PhD) I don't know Decline to state

Will you be the first generation in your family to earn a bachelor's degree? (If your parents/guardians did not earn a bachelor's degree, then you are first-generation.)
Yes
No
Unknown
Decline to state

CSEP Data Portal
Developed and Maintained by the Center for Science and Engineering Partnerships