NASA 2012 Summer of Innovation Program

Appendix 1: Parent Survey

S ummer of Innovation Parent Survey

We are delighted that your child will be part of NASA’s Summer of Innovation. Parents of youth attending this program are being asked to complete this survey. NASA wants to learn more about the youths and their parents taking part in NASA experiences so that we can improve what we offer in the future. There are no “right” or “wrong” answers to any of the questions. The survey should take about 8 minutes to complete the questions.

Your participation in this survey is voluntary. Your child can take part in the program even if you do not take part in the survey.

Securing Your Responses

Protecting your and your child’s privacy is very important to us.

• NASA’s Office of Education, the research organizations doing the evaluation, and the program’s staff will follow strict rules to protect the information you provide.

• The evaluation reports will not include your name, your child’s name, or the name of your child’s school.

• We will not share information that identifies you or your child to anyone outside the evaluation team and the Summer of Innovation staff, except as required by law.

Questions about the Evaluation

• For questions about the study, please email [email protected] or call Alina Martinez, Study Director, at 877-520-6840 (toll-free) or Patricia Moore Shaffer, NASA Office of Education Evaluation Manager, at 202-358-5230 (toll call).

• For questions about your child’s rights as a participant in this evaluation, please call Abt’s Institutional Review Board Administrator, Teresa Doksum at 877-520-6835 (toll-free).

If you wish to participate in this survey, please turn the page. Please return your completed survey along with your other camp registration materials.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. The OMB control number for this collection is <insert number and expiration date>. Return your completed survey along with your other camp registration materials. We estimate that it will take about 8 minutes to read the instructions, gather the facts, and answer the questions. You may send comments on our time estimate above to: by email to [email protected] or by mail to NASA Office of Education, 4U18, 300 E Street SW, Washington, DC, 20546-0001.

NASA Privacy Policy - This notice provides NASA's policy regarding the nature, purpose, use and sharing of any information collected via this form. The information you provide on a NASA-issued form will be used only for its intended purpose, which is to improve NASA’s Summer of Innovation program based on participant feedback. Your responses will be made anonymous and aggregated for review by the Summer of Innovation program management. NASA will protect your information consistent with the principles of the Privacy Act, the e-Government act of 2002, the Federal Records Act, and as applicable, the Freedom of Information Act. Submitting information is strictly voluntary. By doing so, you are giving NASA (and its designated representatives) your permission to use the information for the intended purpose. If you do not want to give NASA permission to use your information, simply do not provide it. However, not providing certain information may result in NASA's inability to provide you with the information or services you desire. For additional information please visit NASA Privacy Policy and Important Notices at http://www.nasa.gov/about/highlights/HP_Privacy.html.

1. Child’s first name: ________________ Last name: __________________________

2. What is your child’s birthday (MM/DD/YYYY)?: Month: __ Day:__ Year: ____

3. What grade level will your child enter in fall 2013?

4^th 5^th 6^th 7^th 8^th 9^th Other: ________________________

4. What is your child’s gender? Male Female

5. Is your child Hispanic or Latino/Latina?  Yes  No

6. What is your child’s race? Check one or more.

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

7. What is the highest level of education you have completed?

 Less than high school (Skip to Question 10)

 High school diploma or GED (Skip to Question 10)

 Associate’s degree

 Bachelor’s degree

 Master’s degree

 Ph.D., M.D., law degree, or other high level professional degree

8. Do you have a degree in a science, technology, engineering, or mathematics field?  

Yes No I don’t know

9. Do you work in a science, technology, engineering, or mathematics-related occupation?

Yes No I don’t know

10. During the last 12 months, has your child participated in any of the following activities outside of school? Check all that apply.

 Science club

 Science competition

 Science camp

 Science study groups or a program where your child was tutored in science

 Visiting a science museum, planetarium, or environmental center

 Reading science books and magazines

 Accessing web sites for computer technology information

 Playing games or using kits or materials to do experiments or build things at home

 Watching programs on TV about nature and discoveries

 None of these

11. Why is your child attending Summer of Innovation? Check all that apply.

 To have fun

 To learn more about NASA and space

 To have something to do

 To learn more about science

 To learn about what scientists and engineers do

 To meet others with interests similar to my child

 Help my child to do well in school

 Not sure

12. How did you hear about Summer of Innovation? Check all that apply.

 A teacher

 A friend or family member

 Newspaper or other advertisement

 Web/Internet search

 Received something in the mail

 School or community center

 Other

We also ask that you provide contact information.
Your Contact Information Your first name: __________________ Your last name: _______________________________
Telephone no.: ( )______________		Alternative telephone no.: ( ) __________________
Best time to call:_________________________________________________________________
Permanent email address (optional): _________________________________________________
Alternative email address (optional): _________________________________________________
Student mailing street address:______________________________________________________
City:___________________________		State: ______________	Zip code: ______________
Emergency Contact (other than parent) Information Please provide contact information for a responsible adult should you not be available.
First Name:_____________________	Last Name: ____________________________________
Relationship to student: ___________________________________________________________
Telephone no.: ( ) _____________		Alternative telephone no.: ( ) __________________
Best time to call: ________________________________________________________________

Thank you!

Please return this completed survey along with your other camp registration materials.