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           Institution
           Community Name

           Address
           City

           State

           Zip or postal Code

           Country

           Program Director (or best person to contact):

           Email:

           Phone:

           Fax:

           Web Address:

           Program Description:

           Sources of funding:

           Are students charged an additional fee:

           Fulltime tenured faculty

           Fulltime Probationary Faculty:

           Fulltime Instructors:

           Fulltime Retired Faculty:

           Fulltime Adjunct Faculty:

           Fulltime Graduate Students:

           Fulltime Residence Hall Staff:

           Parttime tenured faculty

           Parttime Probationary Faculty:

           Parttime Instructors:

           Parttime Retired Faculty:

           Parttime Adjunct Faculty:

           Parttime Graduate Students:

           Parttime Residence Hall Staff:

           Fulltime Academic Staff:

           Parttime Academic Staff:

           Fulltime Non-Academic Staff:

           Fulltime Academic Staff:

           Number of faculty offices in the residence hall:

The approximate percentage of students in each grade level

             The 1st Year:

             The 2nd Year:

             The 3rd Year:

             The 4th Year :

             Graduate Students:

           Total number of students

           Year of the program began

Faculty Rewards for Participation in the Program:

             Release Time:
             Salary Supplement:
             Travel Funds:
             Other:

           Disciplines Represented by the Faculty:

           Suggested Bibliography:

           Willing to Serve as a Consultant: