Form 3135-0098 Panelist Profile Form

PANELIST PROFILE FORM

BASIC INFORMATION

Form of Address (optional): Mr.     Ms.     Mrs.     Miss     Dr.     Other      

Last Name	First Name	Middle Initial
     	     	     
Cell Phone (area code/number)	Home Phone (area code/number)
     	     
Work Phone (area code/number)	FAX (area code/number)
     	     
Email address
     
Title, Role, or Profession
     
Organization (if applicable)
     
Home Address: (Street Address, Apt. #, City, State, Zip)
     
Mailing Address (if different from above): (Street Address, Apt./Suite #, City, State, Zip) Work     Other    
     

Are you self-employed/freelance? Yes     No     Are you a layperson? Yes     No    

Do you have broadband internet access? Yes     No     Recommended by:

Are you a federally registered lobbyist? Yes     No          

SPECIAL CHARACTERISTICS

The NEA does not share this information with any third parties. The information in the following questions is used only for statistical and diversity inclusion purposes.

Which of the following describes your Ethnicity?

Please select only one:

    Hispanic or Latina/o

    Not Hispanic or Latina/o

Which of the following describes your race?

Please select one or more:

    American Indian or Alaskan Native

    Asian

    Black or African American

    Native Hawaiian or Other Pacific Islander

    White

Select one (optional):

    Female    Male

Select the appropriate disability category(ies)

(optional):

    Visual

    Hearing

    Mobility

    Other

Language skills (optional):

Please indicate if you have reading and oral

comprehension and/ or translation skills in the following languages:

    Spanish     French     Other (specify)      

ARTS EXPERIENCE

Make selections from the List of Codes attached to the Instructions.

Field Role Specialization

Primary Arts Expertise                                                

Other Arts Expertise                                                

Other Arts Expertise                                                

Other Arts Expertise                                                

Other Arts Expertise                                                

Other Arts Expertise                                                

WORK EXPERIENCE

Select up to five types of organizations with which you have had working arts experience.

Arts/Cultural Organization

    Arts Organization

    Arts service organization

    Regional arts organization

    State arts agency

    Local arts agency

    Other

    Educational Organization/School Association

    Funding Organization

PANELIST PROFILE FORM - Instructions

INTRODUCTION

What is a Panelist?

Arts Endowment panelists play a central role in reviewing applications for funding. We rely on panels composed of individuals who represent a broad range of artistic and cultural viewpoints and wide geographic and ethnic diversity to provide advice on the artistic excellence and artistic merit of proposals in a variety of funding categories (to learn more about our funding categories go to http://arts.gov/grants). Our panels are composed of both arts professionals and knowledgeable laypersons. Most panelists are arts professionals who are qualified by their activities, training, skills, and/or experience in one or more art forms. Every panel also includes a layperson – someone knowledgeable about the arts but not engaged in the arts as a profession either full- or part-time.

Why Do We Ask for This Information?

We maintain an in-house database with information about individuals’ expertise and experience in the arts to help us identify and select panelists. The NEA does not share this information with any third parties. Responding to some of the questions is voluntary and the information is used only for statistical and diversity inclusion purposes. However, inclusion in this database does not guarantee that someone will be asked to serve on a panel. This information is not shared with anyone outside the NEA.

BECOMING A PANELIST

If you are interested in becoming a panelist, have recently been asked to serve as a panelist, or have been a panelist in the past and want to update your information, please complete and return to the agency both of the following:

1. Panelist Profile Form (Instructions below) so that we will have accurate information about your qualifications and how to contact you.

2. A brief biography (no more than 250-300 words) that includes your current job or occupation and most significant and relevant work in the arts; honors, awards, or other recognitions; board or other memberships; and any relevant international activities.

If you have the form in hard copy, please type or print legibly and check all appropriate boxes. Email the form and bio to us at panelistforms@arts.gov.

HOW TO COMPLETE THE PANELIST PROFILE FORM

Please read the notes and instructions below before you complete the form.

Name

Please provide your legal first and last name.

Home Address/Mailing Address

Please give us your home address, since we keep track of the geographic representation on our panelists by where your legal residence is, not where you work. If this is not also your preferred mailing address, include that as well, and fill in the appropriate checkbox.

Are you a Layperson?

• Consider yourself a layperson if you are knowledgeable about the arts but are not engaged in the arts as a profession, either full-time or part-time. Your expertise may be demonstrated through recognition of your arts knowledge by arts professionals, your involvement in the arts through significant volunteerism, or your demonstrated expertise in artistic genres or arts-related fields.

• If you work in the public, private, or nonprofit sector with primary job responsibilities in the arts or in cultural planning or funding, you cannot be considered a layperson. Even if you do not earn your living through the arts, you may not be a layperson if you also work in the arts as a second profession (e.g., an artist who exhibits work, a paid performer, arts consultant, etc.).

Recommended by:

If you are sending in the form on your own initiative, write in SELF under “Recommended by:” If you are completing the form at someone else’s request, please include that person’s name, title, and organization. If you’re filling out the form recommending someone else, please list your name, title and organization here

Do you have broadband internet access?

Panelists review applications in an online system, so broadband internet access is important to an individual’s ability to easily participate in the review process.

Are you a federally registered lobbyist?

Arts Endowment panels are considered federal advisory committees. On June 18, 2010, President Obama signed a Presidential Memorandum directing agencies in the Executive Branch not to appoint or re-appoint federally registered lobbyists to advisory committees and other boards and commissions. We ask for this information so that we can comply with this prohibition.

Special Characteristics

The Arts Endowment’s enabling legislation requires panels that are racially and ethnically diverse, so we ask for information to comply with the statute. The classifications are prescribed by the Federal Government’s Office of Management and Budget for Federal reporting and statistical activities. They do not determine eligibility for participation on Arts Endowment panels. Identification of gender, disabilities, and language skills is voluntary.

The categories are designed to identify your basic racial and national origin. Please complete both sections a) and b). If you are of mixed racial and/or national origin, you may check more than one box. Choose the category(ies) with which you most closely identify yourself, as described:

Ethnicity:

• Hispanic or Latina/o: A person of Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race.

Race:

• American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and maintaining tribal affiliation or community.

• Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

• Black or African American: A person having origins in any of the black racial groups of Africa.

• Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

• White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Foreign Languages

Please list any non-English language(s) in which you are fluent (reading and oral comprehension).

Arts Expertise

This section lists the skills, experience, and/or training in the arts that you can contribute to a panel. A List of Codes for a variety of arts fields, roles, and areas of specialization is included with the form. Write the appropriate code numbers in the boxes on the Profile Form (one digit per box). Please choose codes that most closely represent your areas of expertise. [NOTE: if you are a layperson (not in the arts as a profession), please make selections that most closely represent the areas of arts expertise/knowledge that you can bring to a panel.]

• Primary Arts Expertise: From the List of Codes choose the arts field (2-digit code), role/function (3-digit code), and specialization/activity (3-digit code) that represent your current area of expertise in the arts.

• Other Arts Expertise: Use this section for additional areas of arts expertise. You may include more than one role/function or specialization/activity in the same art field or include more than one art field, role/function, and specialization/activity.

EXAMPLE: If you are a museum volunteer with extensive knowledge of Asian art, and you also volunteer at a presenting organization but you have no specialized arts presenting knowledge, you would complete the Arts Expertise section as shown here:

ARTS EXPERTISE:

Make selections from the List of Codes included with the Instructions.

Field Role Specialization

Primary Arts Expertise		6	0		0	8	4		0	7	0
Other Arts Expertise		1	0		0	8	4		    	    	    

Work Experience

Use this section to show the various types of organizations that you have worked for:

Select UP TO FIVE types of organizations with which you have had arts experience. These selections may represent both your primary and other arts experience.

EXAMPLE: If you are on the faculty of school, are a member of an orchestra, and are on the board of a local arts agency, you would complete this section as follows:

Please email the completed form and your bio to:

panelistforms@arts.gov

Reporting Burden

The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The Arts Endowment welcomes any suggestions that you might have on improving the panelist profile form and making it as easy to use as possible. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to panelistforms@artsgov. Note: Applicants are not required to respond to the collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number.

OMB No. 3135-0098 Exp. 8/31/2015

Privacy Act

The following notice is furnished in accordance with the Privacy Act of 1974,

5 U.S.C. 552a:

This information is solicited under the authority of the National Foundation on the Arts and the Humanities Act, 20 U.S.C. 951 et seq. and is used to select persons to participate in the Arts Endowment’s application review process. Disclosure of this information may be made to members of Congress and to the general public, upon request in accordance with the Freedom of Information Act (5 U.S. C. 552). Personal biographical data including home address, home telephone number, and social security number will not be released and is exempt from disclosure under FOIA exemption (b)(6).

Equal Opportunity

Arts Endowment programs do not discriminate on the basis of race, color, national origin, sex, disability, or age. For further information, write to Director, Civil Rights Division, National Endowment for the Arts, Washington, DC 20506-0001.

OMB No. 3135-0098, Exp. 8/31/2015

LIST OF CODES [EXISTING CODES]

	Discipline/Field Codes
05	ARTS ADMINISTRATION		95	LOCAL ARTS AGENCIES
10	ARTS PRESENTING		55	MEDIA
20	DANCE		60	MUSEUM
25	DESIGN		65	MUSIC
30	EDUCATION		85	MUSICAL THEATER
35	FOLK & TRADITIONAL ARTS		95	OPERA
40	MULTIDISCIPLINARY ARTS		90	RESEARCH
45	INTERNATIONAL ACTIVITIES		75	THEATER
50	LITERATURE		80	VISUAL ARTS
	Role/Function Codes
010	Actor		250	Filmmaker/Videomaker
015	Administrator/Manager		256	Folklorist
030	Architect		260	Former Board Member
045	Artist		265	Former Staff Member
030	Architect		275	Instrumentalist
050	Artist in Residence		335	Patron (arts)
055	Artist Representative		350	Planner
060	Artistic Director/Staff		355	Playwright
061	Art Historian/Scholar		365	Presenter
070	Arts Consultant		380	Producer
460	Arts Organization Staff		390	Program Director/Staff
075	Assistant/Deputy Director		425	Researcher
085	Arts/Cultural Organization Board Member/Trustee		435	School Board Member
110	Choreographer		475	School Teacher/Arts Specialist
125	Composer/Arranger		431	Singer/Vocalist
140	Conductor		480	Teaching Artist
170	Critic		495	Translator
175	Curator		510	Arts/Cultural Organization Volunteer
185	Curriculum Specialist		525	Writer
190	Dancer
200	Director
210	Dramaturg/Literary Manager
215	Editor
216	Education Director
226	Education Organization Staff
230	Educator
236	Ethnomusicologist
426	Evaluator
240	Executive Director/President

Specialization/Activity Codes
035	African or African-American Arts/Cultures		645	Orchestral/Symphonic
050	Architecture		520	Organizational/Institutional Development
037	Artist Communities		521	Outdoor Drama
060	Arts		535	Painting
775	Arts Center		540	Performance
070	Asian or Asian American Arts/Cultures		550	Performing Arts
601	Audio/Radio		555	Photography
085	Ballet		560	Poetry
100	Chamber Music		561	Post-secondary School
105	Choral		570	Pre-kindergarten/Early Childhood
110	Classical		565	Preservation
115	Community Development		574	Professional/Staff Development
780	Contemporary		580	Public Art
145	Contemporary Art		585	Public Broadcasting
150	Crafts		590	Publications
190	Creative Nonfiction		595	Puppetry
200	Cultural Exchange		600	Radio
210	Curriculum Development		610	Rural
215	Dance		615	Sculpture
120	Digital Arts		616	Secondary School
225	Disability Access		620	Site Specific Work
235	Documentary Film		650	Tap
250	Education		655	Teaching/Staff Development
255	Environmental Design		660	Television
265	Ethnomusicology		695	Urban Design/Planning
061	Evaluation/Assessment		701	Video Games
295	Festivals		765	Visual Artists’ Organizations
300	Fiction
305	Film/Video
325	Folk Arts/Traditional Arts
715	Generalist
340	Grants Management
565	Historic Preservation
405	Jazz
410	Landscape Architecture
350	Latino/Latino-American arts/cultures
420	Long-Range Planning
430	Middle Eastern arts/cultures
435	Modern/Contemporary
455	Music
460	Musical Theater
485	Native American/Alaskan Native arts/cultures

OMB No. 3135-0098 Exp. 8/31/2015