MATHEMATICS AND SCIENCE CENTERS
		    STUDENT SERVICES ACTIVITY LOG/EVENT RECORD



Use this log for all Student Services that are not School-Year (SY) pull-out
programs.  See separate instructions for SY reporting.  This form is to be
completed by the instructor or facilitator/coordinator.

1. INSTRUCTOR(S): _______________________________

2. TITLE OF ACTIVITY/EVENT: _________________________ 3. DATE: _____________

4. SCHOOLS/DISTRICTS INVOLVED:			      5. HOURS:	_____________
   (list here, attach list,
    or indicate "All")		   		      6. GRADE LEVEL:
							 (Check one)
   _____________________________________		___ Pre K
							___ Elementary
   _____________________________________		___ Elem & Mid/Jr.High
							___ Middle/Jr. High
   _____________________________________		___ Mid/Jr. & HS
							___ High School
							___ Other Mixed Levels

7. PRIMARY CONTENT AREA:    8. ATTENDANCE:     9. ENROLLEES BY TYPE:
   (Check one)			______		GENDER:		ETHNICITY:
   ___ Mathematics				____ Female	___ Afr-Amer.
   ___ Science					____ Male	___ Arab-Amer.
   ___ Technology				____ Unknown	___ Asian-Amer.
   ___ Other							___ Caucasian
        Describe: ____________________				___ Hispanic
								___ Native Amer.
								___ Mixed Ancestry
								___ Unknown

10. SECONDARY CONTENT AREA: 				11. DISTANCE LEARNING:
    (Check all that apply - optional)			    ___ Yes     ___ No
    ___ Mathematics
    ___ Science
    ___ Technology					12. MVU
    ___ Other						    ___ Yes     ___ No
        Describe: ____________________
							13. ONLINE LEARNING
							    (not associated with MVU)
14. DESCRIPTION: (Purpose of activity)			    ___ Yes     ___ No


							FOR OFFICE USE:

		        				Primary Strategic Plan Outcome:

							______________________________
							Other Strategic Plans:

							______________________________
							Activity Code #:

							______________________________



Prepared by SAMPI, Western Michigan University, for 2009-2010 use.