Form NIST-1103 Teacher Application for the NIST Summer Institute for Mi

OMB CONTROL NUMBER: 0693-XXXX EXPIRATION DATE: XX/XX/20XX

NIST-1103 U.S. DEPARTMENT OF COMMERCE

(12-2010) NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY

DAO 203-26

Teacher Application for the

NIST Summer Institute for Middle School Science Teachers (NIST Summer Institute)

or the NIST Research Experience for Teachers (NIST RET)

NOTE: This application/questionnaire contains collection of information requirements subject to the Paperwork Reduction Act (PRA). Notwithstanding any other provisions of the law, no person is required to respond to, nor shall any person be subject to penalty for failure to comply with, a collection of information subject to the requirements of the PRA, unless that collection of information displays a currently valid OMB Control Number. The estimated response time for this collection is 1 hour. The response time includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this estimate or any other aspects of this collection of information, including suggestions for reducing the length of this questionnaire, to the National Institute of Standards and Technology, Attn., Anneke Tingle, via email at anneke.tingle@nist.gov or telephone (301) 975-5060.

Check the applicable program: NIST Summer Institute NIST RET

1. Teacher’s Name: ____________________________________________________________________________

2. Nickname (if applicable): ______________________________________________________________________

3. Email Address: ______________________________________________________________________________

4. Complete School Name: ______________________________________________________________________

5. School Address: ____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

6. School District: _____________________________________________________________________________

7. School Supervisor’s Name: ____________________________________________________________________

8. School Supervisor’s Email: ____________________________________________________________________

9. County Science Supervisor’s Name: _____________________________________________________________

10. County Science Supervisor’s Email: _____________________________________________________________

11. Are you a U.S. citizen or a permanent U.S. resident?

1. Yes

2. No

12. If nominated for the NIST Summer Institute, will you be able to commit two (2) full weeks to attend the NIST Summer Institute, July 18-29, 2011, from 9 a.m. to 4 p.m. Monday through Friday or if nominated for the NIST RET, will you be able to commit six (6) full weeks to participate in the NIST RET, Summer 2011, from 8:30 a.m. to 5 p.m. Monday through Friday?

1. Yes

2. No

13. How many years have you taught science at the middle school level (Grades 6, 7, and/or 8)?

Number of years: __________________

14. How many years have you taught any school at any level?

Number of years: ___________________________________

15. In what grade(s) do you teach science for the current school year? Select one primary grade that you spend the majority of your time teaching science. If you teach science for more than one grade, select all additional grades that apply.

	Primary Grade (Select One)	Additional Grades (Select all that apply)
6th grade
7th grade
8th grade

16. In what grade(s) do you expect to teach science for the following school year? Select one primary grade that you expect to spend the majority of your time teaching science. If you expect to teach science for more than one grade, select all additional grades that apply.

	Primary Grade (Select One)	Additional Grades (Select all that apply)
6th grade
7th grade
8th grade

17. What degrees have you earned? (For each degree type, please mark one)

NOTE: Degree options do not include certifications, certificates, endorsements, or licensures.

Type of Degree	Degree Field
	Math	Science	Education	Science Education	Other	None
Bachelor
Master
Ph.D
Ed.D.
Professional Degree (e.g., M.D., L.P.N.)
Specialist Degree
Other (specify):_________________

18. Are you currently working on a degree?

1. Yes

2. No

If yes, what degrees are you currently working on? (For each degree type, please mark one.)

Type of Degree	Degree Field
	Math	Science	Education	Science Education	Other	None
Bachelor
Master
Ph.D
Ed.D.
Professional Degree (e.g., M.D., L.P.N.)
Specialist Degree
Other (specify):_________________

19. For each of the subject areas listed below, indicate which subjects are covered in your classes in the current school year. (Mark one response on each line.)

Subject Area Covered in Your Classes in the Current School Year
	Yes	No
Biology
Earth Science
Space Science
Physics
Chemistry
Weather
Metrology (Measurement Science)
Separating Science (Processes by which components of a mixture are separated from each other, e.g., chromatography, crystallization, gel electrophoresis, mass spectrometry, etc.)
Forensic Topics
Other (specify): ___________________________________

20. Which of the following professional development activities have you participated in during the past three (3) years? (Mark all that apply.)

1. Learning content knowledge related to science

2. Learning content knowledge not related to science

3. Selecting and adapting instructional material

4. Using research to inform curriculum with standards

5. Learning strategies for aligning curriculum with standards

6. Working with diverse and/or minority students, special education students, and/or students with limited English proficiency

7. Developing leadership skills in working with peers

8. Developing skills in working with parents, school boards, or other outside of the school

9. Using technology in instruction

10. Learning how to use data and statistics

11. Other (specify): ___________________________________________

21. Not counting the NIST Summer Institute or NIST RET, have you participated in any professional development activities in a laboratory, research, or industrial setting in the past 3 years?

1. Yes

2. No

If yes, provide the following information about any professional development activities in which you participated in the past 3 years:

Name of Program	Sponsoring Agency	Type of setting (e.g., government, industry, university)	Year	Duration (number of days)

22. How did you learn about the NIST Summer Institute or NIST RET program? (Mark one response.)

1. Noticed an open invitation and decided to apply.

2. Encouraged by a former NIST Summer Institute or NIST RET participant and decided to apply.

3. Encouraged/recruited/designated by an administrator (excluding school principal) or specialist at the school or district level (e.g., superintendent, curriculum specialist, department head or chair, or science coach).

4. Encouraged/recruited/designated specifically by my school principal.

5. Encourage/recruited/designated by local leadership council/curricular committee or professional development program or organization.

6. Other (Specify). ______________________________________________________

23. For RET nominated teachers only, when did you attend a prior NIST Summer Institute (dates and year)? ____________________

24. Statement of Motivation: In the space provided below (may not exceed space provided) Describe why you would like to attend the NIST Summer Institute or participate in the NIST Research Experience for Teachers.

*Teacher’s Signature: _______________________________________ Date: ________________________

*By signing this application, I certify that the statements herein are true, complete, and accurate to the best of my knowledge. I also agree to comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties (U.S. Code, Title 218, Section 1001).

NIST-1103 (12-2010)