Department of Psychology Alumni Tracking Form

Providing an e-mail address will help us keep you better connected to what is happening in the Psychology Department. Also you will receive issues of our Psychology e-newsletter twice a year.

Please help us by using the form below to update your information.

Name Name First Last
Full name while at OSU (if different than above) Full name while at OSU (if different than above) First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Alternate Email
Phone Phone - ### - ### ####
Alternate Phone Alternate Phone - ### - ### ####
OSU Undergraduate Information
Graduation Year
Degree Earned
Primary Major
Secondary Major/Minor
While an undergraduate at OSU, were you involved in any of the following? (check all that apply)

While an undergraduate at OSU, were you involved in any of the following? (check all that apply) Psychology Diversified Students Program American Indians Into Psychology Program Undergraduate Research
If you selected Undergraduate Research, please list your research advisor
Occupational Information
Employer
Title
Department
Address Address
City State / Province / Region Country
Please indicate the primary nature of your current occupational setting

Please indicate the primary nature of your current occupational setting Academic (College/University Setting) Administrative Appointment Clinical Treatment Setting Government/Public Agency Private/Corporate Setting Research Setting Other Other
Graduate Studies Information

Please complete this section ONLY if you have or intend to complete post-bachelor studies (all others proceed to next section).

If you have already completed (or are currently enrolled in) formal graduate studies, please complete this section. If you are applying to (or plan to apply to) formal graduate studies in the future, please complete the Future Plans section below.
Are you currently enrolled in a Graduate Degree Program?

Are you currently enrolled in a Graduate Degree Program? Yes No
Have you ever completed a Graduate Degree Program?

Have you ever completed a Graduate Degree Program? Yes No
Name of Institution
Location of Institution Location of Institution
City State / Province / Region Country
Type of Program (i.e., MS, PhD, PsyD, etc.)
Field of Study
Specialization
Highest Degree Earned
Date Degree Awarded
Name of Institution 2 (Complete if you attended more than one program in graduate studies)
Institution 2 Address Institution 2 Address
City State / Province / Region Country
Type of 2nd Program (i.e., MS, PhD, PsyD, etc.)
Field of 2nd Study
Specialization of 2nd Study
Highest Degree 2 Earned
Date 2nd Degree Awarded
Post-Doctoral Information
Did you complete a post-doctoral fellowship?

Did you complete a post-doctoral fellowship? Yes No
Site
Dates
Designation of Duties
For Clinical Psychologists

(all others please continue to next section)
Have you ever been licensed?

Have you ever been licensed? Yes No
In what year were you first licensed?
Are you currently licensed?

Are you currently licensed? Yes No
List all states/jurisdictions in which you are currently licensed:
Have you ever been ABPP certified?

Have you ever been ABPP certified? Yes No
Are you currently ABPP certified?

Are you currently ABPP certified? Yes No
List all certifications that you currently hold:
Future Plans

Please list your educational or career goals for the future.
Do you plan to apply to graduate school?

Do you plan to apply to graduate school? Yes No
What field of study are you planning on pursuing?
What types of graduate programs are you applying to? (MS, PhD, PsyD, other?)
What most influenced your decision to pursue graduate studies?
Career Goals:

What are your long-term career goals? (professor, researcher, clinician, etc?)
Miscellaneous Information
What was the most important thing you learned while attending OSU?
What advice would you give to current or prospective students?
Tell us a little about your life (e.g., Where do you live and work, your current family, veteran status, and future plans)?
Please list significant accomplishments / publications or any comments you would like to share
What is your personal/professional webpage address (If applicable)?
Do you have any family or friends that are also OSU PSYC alumni and will you share this site with them?

Do you have any family or friends that are also OSU PSYC alumni and will you share this site with them? Yes No
If you are visiting Stillwater, would you be willing to speak to a group of students about your profession or life experiences?

If you are visiting Stillwater, would you be willing to speak to a group of students about your profession or life experiences? Yes No
Please share any final comments you would like to add
The psychology dept can make this information available to others at their discretion (alumni directory, alumni spotlight, etc)

The psychology dept can make this information available to others at their discretion (alumni directory, alumni spotlight, etc) Yes No, I would prefer that this information not be shared outside the Psychology Dept Faculty and Staff

Department of Psychology Alumni Tracking Form

Department of Psychology Alumni Tracking Form

OSU Undergraduate Information

Occupational Information

Graduate Studies Information

Post-Doctoral Information

For Clinical Psychologists

Future Plans

Miscellaneous Information