DO-IT Prof Institution Data Collection Form


Name of Institution:__________________________________________


Check one: 
____DO-IT Prof Team Member Institution   ____DO-IT Prof Partner Institution


Contact information for person completing survey:

Name: ________________________________________________________



Address: _____________________________________________________



City: __________________ State: _________ Zipcode: ___________



Phone: _________________ Email: ______________________________


Check each category that applies to this institution:

____Four-year    ____Public/Private

____Two-year     ____Other. Specify:__________




Check the types of degrees your institution grants. 

____Associate     ____Bachelor's     ____Master's

____Doctor's      ____First Professional

Enrollment

Check the term for which data is reported.

____Fall 1999     ____Fall 2000    ____Fall 2001    ____Fall 2002



Write the total number of students (headcount) enrolled in
credit-bearing classes at your institution for this term. __________



    Write the number of students enrolled in credit-bearing classes who
    have identified themselves as belonging to each of the following
    groups:

    ____White, non-Hispanic (a person having origins in any of the
        original peoples of Europe, North Africa, or the Middle East)

    ____Black, non-Hispanic (a person having origins in any of the
        black racial groups in Africa)


    ____Hispanic (a person of Mexican, Puerto Rican, Cuban, Central or
        South American, or other Spanish culture or origin, regardless of
        race)

    ____Asian or Pacific Islander (a person having origins in any of the
        original peoples of the Far East, Southeast Asia, the Indian
        subcontinent, or the Pacific Islands)


    ____American Indian or Alaskan Native (a person having origins in any
        of the original peoples of North America and maintaining cultural
        identification through tribal affiliation or community recognition)

    ____Other or declined to state



    Note: Because some students will check more than one race or 
    ethnicity, this section may total more than the institution headcount.

 
    ____Male

    ____Female

    ____Having a disability


        Write the number of students who have the following
        disabilities. Disability categories are those used by the
        U.S. Department of Education National Center for Education Statistics
        (NCES).

        ____Visual impairment

        ____Hearing impairment or deaf Speech impairment 

        ____Orthopedic impairment 

        ____Learning disability 

        ____Other impairment or disability


        Note: Because some students may report multiple disabilities, this
        section may total more than the total number of students reporting a
        disability.

Educational Attainment

Indicate the academic year for which data is reported. 

____Fall 1998 through Summer 1999 

____Fall 1999 through Summer 2000 

____Fall 2000 through Summer 2001 

____Fall 2001 through Summer 2002



Write the total number of the following attained by students at this institution during this time period. 

____Vocational Certificates 

____Associate Degrees 

____Bachelor's Degrees 

____Master's/Doctor's/First Professional Degrees



Write the total number of the following attained by students with disabilities at this institution during this time period. 

____Vocational Certificates 

____Associate Degrees 

____Bachelor's Degrees 

____Master's/Doctor's/First Professional Degrees



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