Form NIST-1103 Teacher Application for the Middle School Science Teache

OMB CONTROL NUMBER: 0693-0059 EXPIRATION DATE: ##/##/####
U.S. DEPARTMENT OF COMMERCE
NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY

NIST-1103
(REV. 09-2011)
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
[email protected] 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?
a.
b.

Yes
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, from 9 a.m. to 4 p.m. Monday through Friday on the dates specified in the Announcement of Federal
Funding Opportunity (FFO) or if nominated for the NIST RET, will you be able to commit six (6) full continous weeks
to participate in the NIST RET, from 8:30 a.m. to 5 p.m. Monday through Friday during the summer?
a.
b.

Yes
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.
Degree Field
Type of Degree
Math
Bachelor
Master
Ph.D
Ed.D.
Professional Degree (e.g., M.D., L.P.N.)
Specialist Degree
Other (specify): _________________

NIST-1103 (REV. 09-2011)

Science

Education

Science
Education

Other

None

18. Are you currently working on a degree?
a. Yes
b. No
If yes, what degrees are you currently working on? (For each degree type, please mark one.)
Degree Field
Type of Degree
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
Biology

Earth Science

Space Science

Physics

Chemistry

Weather

Other (specify): ___________________________________

NIST-1103 (REV. 09-2011)

No

20. Which of the following professional development activities have you participated in during the past three (3) years?
(Mark all that apply.)
Learning content knowledge related to science
Learning content knowledge not related to science
Selecting and adapting instructional material
Using research to inform curriculum with standards
Learning strategies for aligning curriculum with standards
Working with diverse and/or minority students, special education students, and/or students with limited
English proficiency
Developing leadership skills in working with peers
Developing skills in working with parents, school boards, or other outside of the school
Using technology in instruction
Learning how to use data and statistics
Other (specify): ___________________________________________

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.

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?
a. Yes
b. 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.)
a.
b.
c.
d.
e.
f.

Noticed an open invitation and decided to apply.
Encouraged by a former NIST Summer Institute or NIST RET participant and decided to apply.
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).
Encouraged/recruited/designated specifically by my school principal.
Encourage/recruited/designated by local leadership council/curricular committee or professional
development program or organization.
Other (Specify). ______________________________________________________

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

NIST-1103 (REV. 09-2011)

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 (REV. 09-2011)