As an alumni of the HHMI/NIH/MCPS Internship for High School Students, we ask that you kindly take a few moments to complete this brief survey about the program in which you participated.

The information you provide will help us to guarantee a more valuable and rewarding educational experience for our students, and will help us to obtain the continued funding that makes this opportunity possible for other gifted students like yourself.

All information remains strictly confidential.   

When finished, simply click on the 'Submit Questionaire' button below.

If you have any problems using this form, please email Gloria Seelman at
seelmang@mail.nih.gov. Thank you.

required fields
I. Contact Information
1. Name:

   
 First  MI  Last
2. Preferred E-mail Address:    userid@server.com
3. Current Address:  
 
 
(DC for Washington D.C.)  
 
City
 State
Zip     
4. Permanent Address:
 
(DC for Washington D.C.)  
   
City
 State
Zip     
    5. Telephone Contact
-
-  
Work Phone #
Permanent Phone #
 
II. Academic Information
6. High School Attended
  
Year of H.S. Graduation:
 
7. Do/did you attend college?  
If yes, College Name:
City, State:
8. Did you graduate from college?  
Year of college graduation
College Major:
9. Do/did you attend Graduate School?  
If yes, Graduate School Name:
City, State:
If no, do you plan to attend Graduate School?
Where?
10. Did you complete Graduate School?  
Year of Graduate School completeion:
Graduate Degree Received:
11. Are you currently employed in a science-related field?  
Current Job Title:
Name of Employer:
 
III. HHMI/NIH/MCPS Student Internship Information
12. Title of your Internship Project:
 
Year:
 
13. Preceptor:
 
Department / Institute:
 
14. After completing your internship, did you return to work at NIH?  

Explain:
15. Did you publish as a result of your work at NIH?  

If Yes, what was the title,
journal name, and
date of publication?

16. Honors, awards, and/or scholarships you have received:
17. Did your internship experience at NIH influenced your career choice?   

Explain:


18. Is there any other information you would like to share?
Please click the 'Submit Questionaire' button ONLY ONCE when finished.

  fields are required
 

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Updated on September 22, 2006

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