NSTI 001 Summer Teacher Institue Application

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NST Application Form
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PRA Statement of Burden
The United States Patent and Trademark Office (USPTO) is using this form as an application for the National Summer Teacher Institute.
This application is voluntary, includes
questions and should take approximately  minutes to complete. This information collection
contains 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. Please direct comments on
the time needed to complete this worksheet, and/or suggestions for reducing this burden to the Chief Administrative Officer, U.S. Patent
and Trademark Office, U.S. Department of Commerce, P.O. Box 1450, Alexandria, VA 22313-1450.

All fields are required in order to complete the NST application.
. Applicant's First Name:

. Applicant's Last Name:

. School Name:

. School District or County:

. School Website:

. School Address:

. City:

. State or U.S. Territory:
State Selector

. Zip Code:

. Applicant's Address:

. City:

. State or U.S. Territory:
State Selector

. Zip Code:

. Telephone (where you can be reached this summer):
(xxx-xxx-xxxx)
. E-mail Address (that you have access to this summer):

. Name of Approving Principal or Administrator:

. Contact Number of Approving Principal or Administrator:
(xxx-xxx-xxxx)
. E-mail Address of Approving Principal or Administrator:

. f selected for participation in the NST , agree to attend all sessions during the week of July

-

,

and

p
p
g
g
y
will make reasonable efforts, where applicable, to incorporate the lessons learned during the nstitute in my
classroom and school district/county during the
academic year. n addition, will cooperate in any
reasonable efforts to share my experiences and outcomes with other teachers at the nstitute and with the Office
of Education and Outreach at the USPTO:
Yes

No

. have been a full-time, licensed teacher in an elementary, middle or high school (public or private) in the
United States for at least three years:
Yes

No

f "No", Please Specify Other: N/A

. have a strong desire to incorporate “making,” inventing, or innovation into the learning environment as a
means for enhancing student interest in STEM learning:
Yes

No

. have an interest in increasing student knowledge and understanding of the concepts of intellectual property,
including creation and protection of intellectual property:
Yes

No

. Please check all STEM or STEM-related* courses you have taught during the
Academic Year: (STEM
is defined as any course in the area of science, technology, engineering, or mathematics. *STEM-related applies
broadly to any content area course that involves the use or application of any field of science, technology,
engineering or mathematics or any combination thereof):
(Check all that apply)
Algebra
Biology
Botany
Calculus
Chemistry
Computer Science
Computer-Aided Design
Creative Thinking
Design Thinking

Engineering
Geometry
Graphic Design
ndustrial Design
ntellectual Property
nvention Concepts
Materials Science
Mechanics
Other Math Course

Physics
Rapid Prototyping
Robotics
Technology
Trigonometry
Visualization
Welding/Shop
Woodworking
Other

if other provide details: N/A

. Please check all STEM or STEM-related* courses you will teach during the
 Academic Year: (STEM is
defined as any course in the area of science, technology, engineering, or mathematics. *STEM-related applies
broadly to any content area course that involves the use or application of any field of science, technology,
engineering or mathematics or any combination thereof):
(Check all that apply)

Algebra
Biology
Botany
Calculus
Chemistry
Computer Science
Computer-Aided Design
Creative Thinking
Design Thinking

Engineering
Geometry
Graphic Design
ndustrial Design
ntellectual Property
nvention Concepts
Materials Science
Mechanics
Other Math Course

Physics
Rapid Prototyping
Robotics
Technology
Trigonometry
Visualization
Welding/Shop
Woodworking
Other

if other provide details: N/A

. Please check examples of either informal or formal educational programs where you have taught or mentored
students in areas related to one or more of the following: nvention, nnovation, Making, or Entrepreneurship.
(Check all that apply)
Computer Science Club
Entrepreneurship Club
nvention Competitions

nventors Club
Making/Design/Do- tYourself (D Y)projects
Robotics Programs

Science Fair Projects
Scouting
-H

Other if other provide details: N/A

. have a strong desire to improve teaching and learning in either formal or informal environments and
especially as it relates to the fields of STEM, innovation, or intellectual property:
Yes

No

. My school principal or administrator/superintendent has endorsed my application to the USPTO National
Summer Teacher nstitute. Endorsement means my principal or administrator is aware of my application to this
program and has agreed to support my efforts to take the lessons learned through participation in this nstitute
back to the classroom or to my school district. This also includes support by the administrator to allow the
teacher to cooperate with any reasonable efforts in sharing learning experiences and outcomes with other
teachers at the nstitute and with the USPTO:
Yes

No

. understand that my principal or administrator may be contacted to verify awareness of my application to
participate in this program:
Yes

No

. acknowledge that if am selected to participate in this program the USPTO may contact my principal or
school administrator to verify their endorsement:
Yes

No

. Please share any additional information that may be relevant to your interest in participating in the USPTO
National Summer Teacher nstitute, which will take place during the week of July - ,
. (Please limit your
response to
words or less). Please include your interest, experience, and motivation for applying to NST . For
more information, please visit our NST FA page at the following http://bit.ly/NST _FA
(http://bit.ly/NST _FA ):

Submit

Privacy Act Statement
The authority for the collection of this information is U.S.C. §
,
U.S.C. § , and E.O.
. The information you
provide will be used to verify your identity and administer participation in the National Summer Teacher nstitute. The
information you provide is protected from disclosure to third parties in accordance with the Privacy Act. However,
routine uses of this information may include disclosure to the following: Congressional offices; Federal, state, local or
foreign agencies; a court, magistrate or administrative tribunal; law enforcement; agents or contractors; the
Department of Justice; the National Archives and Records Administration; and agency customers in the course of
distributing patent and trademark business information. Disclosure of the information by you is voluntary; however,
failure to provide any part of the requested information may result in our inability to enroll you in the program. The
applicable Privacy Act System of Records Notice for this information request is Commerce PAT/TM- , Dissemination
Events and Registrations, available at http://www.osec.doc.gov/opog/PrivacyAct/SORNs/pat-tm- .html
(http://www.osec.doc.gov/opog/PrivacyAct/SORNs/pat-tm- .html).

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