Confidential Student Outcome Report

Confidential Student Outcome Report Form for Colleges Participating in the Brother James Kearney Scholarship for the Blind

Name of Student (or Recent Graduate):*
First Middle Last
Student's Email Address
Student's Phone Number
Name of College:*
Time of this Report*
Enter the date for when you are submitting this report.
When are you submitting the form relative to your college graduation?*
Thank you for your promise, as a condition of receiving Lavelle-Brother Kearney Scholarship support, to provide your college (normally, the Disability Services Office) with the education and employment outcome data specified below at three times: (1) when you graduate (or withdraw) from the college, (2) one year after such graduation, and (3) at any other time, within five years of my graduation, at which your college may decide to seek such data through alumni surveys. By signing your student release form, you have authorized your college to convey this information to the Lavelle Fund’s board and staff, who will not share it with anyone outside the Fund.

Please Report on the Following Outcomes:
College Outcomes – Major:
Reported Only at the Time of Graduation
College Outcomes – Degree Earned:
Reported Only at the Time of Graduation
College Outcomes – Degree Date Conferred - Year:
College Outcomes – Degree Date Conferred - Month:
Employment Outcomes – Job Title, If Employed:
Employment Outcomes – Name of Employer:
Employment Outcomes – Full or Part-time:
Employment Outcomes – If seeking work, list vocational objective:
Advanced Education Outcomes – Degree Sought:
Including field of study, if not self-evident.
Advanced Education Outcomes – Name of College or University:
Advanced Education Outcomes – Degree Earned:
Advanced Education Outcomes – Degree Date Conferred:
Other Status – If Not Currently Employed or Studying:
Signature of Student:
Date
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

Please Report on the Following Outcomes: