Form 3135-0098 Panelist Profile Data Collection

01/21/21 Panelist Profile Data Collection 13

Name and Contact Information Name
Salutation	Mrs. Dr. Mr. Mrs. Ms. Prof. Rev.
First Name	* * *
Middle Name	* * *
Last Name	* * *
Nickname	* * *
Suffix	-- Select -- II III IV CPA DDS Esq JD Jr LLD MD PhD Ret RN Sr DO
Email
Primary Email
Alternate Email	* * *
Addresses
Occupation	* * *
Work Street Address 1	* * *
Work Street Address 2	* * *
Work Street Address 3	* * *
Work City	* * *
Work State	-- Select --
Work Postal Code	* * *
Work Country	-- Select --
Home Street Address 1	* * *
Home Street Address 2	* * *
Home Street Address 3	* * *
Home City	* * *
Home State
Home Postal Code	* * *
Home Country	-- Select --

Phone Number(s)

Add Phone

Categories

Select categories from the list below. Use the arrow next to each category heading to expand the list of options.

A. Panelist Tags

• Federally registered lobbyist: Can’t serve on NEA panels

• Layperson: You are not engaged in the arts as a profession, or your primary job is not in the arts

B. Panelist Ethnicity (Pick One. Note: All federal government agencies must use these standards that are issued by the U.S. Office of Management and Budget.)

• Hispanic or Latina/o: A person of Hispanic, Latino, or Spanish origin; may be of any race.

• Not Hispanic or Latina/o

C. Panelist Race (You may choose more than one. Note: All federal government agencies must use these standards that are issued by the U.S. Office of Management and Budget.)

• American Indian or Alaskan Native: A person with origins in the original peoples of N./S. America.

• Asian: A person with origins in the original peoples of the Far East/SE Asia/Indian subcontinent.

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

• Native Hawaiian or Other Pacific Islander: A person w/origins in orig. peoples of HI/GU/Samoa/Pac Is

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

D. Panelist Gender (Optional/Pick One. Note: All federal government agencies must use these standards that are issued by the U.S. Office of Management and Budget.)

• Female

• Male

E. Panelist Disability. Optional. Select your disability, if applicable. Let your staff contact know if you will need any special accommodations during your panel service.

• Hearing

• Mobility

• Other

• Visual

F. Panelist Foreign Language(s). Optional. Select any non-English language(s) in which you are fluent (reading and oral comprehension).

• American Sign Language

• Arabic

• Chinese

• Danish

• Dutch

• Farsi

• French

• German

• Greek

• Hebrew

• Hindi

• Indonesian

• Italian

• Japanese

• Korean

• Native language

• Other

• Portuguese

• Russian

• Spanish

• Swahili

• Swedish

• Turkish

• Vietnamese

G. Panelist Organization Type. Select types of organizations with which you have had arts experience. You may choose more than one box.

• Arts organization

• Arts service organization

• Educational organization or school association

• Funding organization

• Local arts agency

• None of the above

• Other

• Regional arts organization

• State arts agency

H. Panelist Field. You may choose more than one. Note: If you are a layperson, make selections that most closely represent the areas of arts expertise/knowledge that you can bring to a panel.

• Arts Administration

• Arts Presenting

• Dance

• Design

• Education

• Folk & Traditional Arts

• International Activities

• Literature

• Local Arts Agencies

• Media

• Multidisciplinary Arts

• Museum

• Music

• Musical Theater

• Opera

• Research

• Theater

• Visual Arts

I. Panelist Role. You may choose more than one. Note: If you are a layperson, make selections that most closely represent the areas of arts expertise/knowledge that you can bring to a panel.

• Actor

• Administrator/Manager

• Architect

• Art Historian/Scholar

• Artist

• Artist in Residence

• Artist Representative

• Artistic Director/Staff

• Arts Organization Staff

• Arts/Cultural Organization Board Member/Trustee

• Arts/Cultural Organization Volunteer

• Assistant/Deputy Director

• Choreographer

• Composer/Arranger

• Conductor

• Consultant

• Critic

• Curator

• Curriculum Specialist

• Dancer

• Director

• Dramaturg/Literary Manager

• Editor

• Education Director

• Education Organization Staff

• Educator

• Ethnomusicologist

• Executive Director/President

• Filmmaker/Videomaker

• Folklorist

• Former Board Member

• Former Staff Member

• Instrumentalist

• Patron (arts)

• Planner

• Playwright

• Presenter

• Producer

• Program Director/Staff

• Researcher

• School Board Member

• School Teacher/Arts Specialist

• Singer/Vocalist

• Teaching Artist

• Translator

• Writer

J. Panelist Specialization. You may choose more than one. Note: If you are a layperson, make selections that most closely represent the areas of arts expertise/knowledge that you can bring to a panel.

• African or African-American Arts/Cultures

• Architecture

• Artist Communities

• Arts

• Arts Center

• Asian or Asian American Arts/Cultures

• Audio/Radio

• Ballet

• Chamber Music

• Choral

• Classical

• Community Development

• Contemporary Art

• Crafts

• Creative Nonfiction

• Cultural Exchange

• Curriculum Development

• Dance

• Digital Arts

• Disability Access

• Documentary Film

• Education

• Environmental Design

• Ethnomusicology

• Evaluation/Assessment

• Festivals

• Fiction

• Film/Video

• Folk Arts/Traditional Arts

• General Director

• Generalist

• Grants Management

• Historic Preservation

• Jazz

• Landscape Architecture

• Latino/Latino-American arts/cultures

• Long-Range Planning

• Middle Eastern arts/cultures

• Music

• Musical Theater

• Native American/Alaskan Native arts/cultures

• Orchestral/Symphonic

• Organizational/Institutional Development

• Outdoor Drama

• Painting

• Performance

• Performing Arts

• Photography

• Playwriting

• Poetry

• Post-secondary School

• Pre-kindergarten/Early Childhood

• Preservation

• Professional/Staff Development

• Public Art

• Public Broadcasting

• Publications

• Puppetry

• Radio

• Rural

• Sculpture

• Secondary School

• Site Specific Work

• Tap

• Translation

• Teaching/Staff Development

• Television

• Urban Design/Planning

• Video Games

• Visual Artists’ Organizations

Biography

Please enter your biography below. You may also provide a URL for an online biography or personal web site. You can also add your ORCiD . Your browser does not support inline frames or is currently configured not to display inline frames. Show/Hide Border Table Properties Delete Table Row Your browser does not support inline frames or is currently configured not to display inline frames. Insert Row Above Insert Row Below Delete Row Column Your browser does not support inline frames or is currently configured not to display inline frames. Insert Column to the Left Insert Column to the Right Delete Column Cell Your browser does not support inline frames or is currently configured not to display inline frames. Merge Cells Horizontally Merge Cells Vertically Split Cell Horizontally Split Cell Vertically Delete Cell Cell Properties Table Properties Properties... Image Map Editor Properties... OpenLink Remove Link Insert Select Cut Copy Paste Paste from Word Paste Plain Text Paste As Html Paste Html Plain text character count: 570/750max. Formatted character count: 570/800 max.
Biography/CV URL	* * *
ORCID iD	* * *
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Social Security Number

If you are serving on a panel, and would like to receive payment for your work, you will enter your social security number here. However, you may wait to provide this information until your service is confirmed.

If your social security number is on record for the purposes of reporting payments or honorarium to the IRS, the last four digits are displayed here.

Click Edit SSN to modify this value. Upon saving, only the last four digits will be displayed.

Social Security Number:

Edit SSN

OMB No. 3135-0098 Exp. TBD

Paperwork Reduction Act Statement

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. Note: You are not required to respond to the collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number.

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 National Endowment for the Arts’ 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). Bottom of Form