Colorado Space Grant Student Awardee Reporting Form

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The information collected on this form is used to report details about students who received funds (hourly wage, stipend, and/or scholarship) from NASA's Colorado Space Grant program. It is entered in NASA's Office of Education Program Management (OEPM) system. Self-identification of citizenship, gender, race, ethnicity, disability and veteran status is essential for effective data collection and analysis. Information provided will be used for statistical purposes only. Your cooperation providing accurate information is critical.

Full Name (First Middle Last): *

Enrolled Institution: *

Major/Certificate Program/Focus: *

Minor/Secondary Focus

Primary email address: *

Secondary email address (if applicable):

Year of Birth: *

Expected Graduation month and year:

Gender: *

Female

Male

Non-binary

Trans male/ Trans man

Trans female / Trans woman

Genderqueer / Gender non-conforming

Prefer not to disclose

Other:

Race/Ethnicity: *

Select all that apply

Asian

Black or African American

Indigendous Alaskan

Indigenous American

Indigenous Hawaiian

Latino or Hispanic

Pacific Islander

White

Other:

Required

Disability *

Select all that apply

I do not have a disability

I do not wish to identify my disability status.

Vision

Hearing

Paralysis

Missing Extremities

Neurodiverse

Learning

Other:

Required

Have you served in the United States Military Service? *

Yes

I am a first generation student (parents do not have college degree) *

Yes

I am a Pell Grant recipient: *

Yes

Not Sure

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