Name:

Date:

Division/Dep't

Ext:

Email:

Date Needed:

1. Please describe your request:

2. What is the primary purpose of your request?

State or federal reporting

Major planning/ evaluation

Prerequisite/Co- requisite study

Assessment

Grant Application

Report to outside agency

Course/Program SLO

Program Review

Accreditation

Other:

3. What questions do you want the data to answer?

4. How will this information impact current practice?

5. Please specify how the project supports applicable college plans (Master Plan, Institutional Goals, Unit Plans, Divisional/Departmental/Program Plans, etc.):

BCC Educational Master Plan:

Goal #

Objective:

6. Please check all that apply:

Will help us measure the extent to which we meet an objective or outcome (key performance indicator) specified in our three-year plan. If so, please state the objective/outcome as described in your plan.

Required for departmental, divisional or institutional accreditation.

Will help assess student learning and success.

Will provide data for a grant proposal.

Will provide data for institutional review.

Other:

7. How do you intend to use the information?

8. For external reporting: (e.g. state government/agency, ACCJC/WASC federal government/agency, outside organization, etc.)

A. Please include any relevant specification or definitions here.

B. Enter Name of external agency/organization: