V/T Education Student Placement Status - PART I
Northwest-Shoals Community College
These data are required for program improvement and reporting activities. Part I is to be completed when you enter your program, and Part II is to be completed when you exit your program. Data on race, sex, and disabilities will be aggregated and used for reporting purposes only.
Response Required Please select a program of study from this list (choose carefully and remember to drop by the admissions office and fill out a change-of-major form if you change your major.) Thank you.
PART I: Student Demographic Data and Employment Status - Program Entry
The information provided is for statistical purposes only and will only be provided in collegewide statistical reports.
Name:
Date:
Student ID (SSN No. without dashes):
Address:
Phone Number: (Please include area code)
Sex:
Male Female
Race:
African American Asian Caucasian Hispanic Native American Other
Single Parent:
Yes No
Special Population Status (Please check all that apply):
Pell Grant Recipient
Developmental courses
ESL
Americans with Disabilities Act
Incarcerated/Corrections
WIA
Purpose for Enrolling:
To take course(s) for self improvement/personal interest
To take job-related courses
To obtain or maintain certification
To take selected Occupational/Technical courses
To obtain Occupational Certificate
To obtain General Certificate
To obtain Associate in Arts (AA) Degree
To obtain Associate in Science (AS) Degree
To obtain Assiciate in Applied Science (AAS) Degree
To take selected courses for four-year degree
Other
Employment Status at Time of Program Entry:
Employed in related field
Employed in non-related field
Not employed
Employer Name:
Employer Phone Number:
Employer Address:
Job Title:
Employment:
Full-Time
Part-Time
Response RequiredIndicates Response Required