Form NSTI001 Summer Teacher Institute Application

PTO/NSTI/001 Approved for use through XX/XXXX

OMB 0651‐00XX

U.S. Patent and Trademark Office; U.S. DEPARTMENT OF COMMERCE

Under the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.

Doc Code: USPTO NATIONAL SUMMER TEACHER INSTITUTE – August 10-14, 2014 NSTI001
Document Description: Application for Participation in USPTO National Summer Teacher Institute

APPLICATION TO PARTICIPATE IN THE USPTO NATIONAL SUMMER TEACHER INSTITUTE (NSTI)
Applicant Name	School Name	School District or County
Applicant Mailing Address	School Mailing Address	School Website
Phone Number (please indicate work/mobile)	Email Address	Name of approving principal or administrator
Please answer all questions below and submit on-line at http://uspto.gov/education If selected for participation in the NSTI, I agree to attend all sessions beginning on August 10, 2014 and ending on August 14, 2014 and to make reasonable efforts, where applicable, to incorporate the lessons learned during the Institute in my classroom and school district/county during the 2014-2015 academic year. In addition, I will cooperate in any reasonable efforts to share my experiences and outcomes with other teachers at the Institute and with the Office of Education and Outreach at the USPTO.  Yes  No I have been a full-time, licensed teacher in a middle or high school (public or private) in the United States for at least three years.  Yes  No I 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 I 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 2013-2014 Academic Year: STEM is defined as any course in the area of Science, Technology, Engineering, or Mathematics.  Biology  Chemistry  Physics  Computer Science  Botany  Robotics  Technology  Engineering  Materials Science  Algebra  Geometry  Trigonometry  Calculus  Other Mathematics course  Mechanics  Woodworking  Welding/Shop  Rapid Prototyping  Graphic Design  Industrial Design  Computer-Aided Design Design Thinking  Invention Concepts  Creative Thinking  Visualization  Intellectual Property  Other_________________ (Please specify) Please check all STEM or STEM-related* courses you will teach during the 2014-2015 Academic Year: STEM is defined as any course in the area of Science, Technology, Engineering, or Mathematics.  Biology  Chemistry  Physics  Computer Science  Botany  Robotics  Technology  Engineering  Materials Science  Algebra  Geometry  Trigonometry  Calculus  Other Mathematics course  Mechanics  Woodworking  Welding/Shop  Rapid Prototyping  Graphic Design  Industrial Design  Computer-Aided Design Design Thinking  Invention Concepts  Creative Thinking  Visualization  Intellectual Property  Other__________ (Please specify) *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. Please check examples of either informal or formal educational programs where you have taught or mentored students in areas related to one of the following: Invention, Innovation, “Making”, or Entrepreneurship.  Making/Design/Do-It-Yourself (DIY) projects  Invention Competitions  Robotics Programs  Science Fair Projects  Scouting  Inventors Club  Entrepreneurship Club  Computer Science Club 4-H  Other ________________________(Please specify) I 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 Summer Teacher Institute. 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 Institute 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 Institute and with the USPTO.  Yes  No I understand that my principal or administrator may be contacted to verify awareness of my application to participate in this program.  Yes  No I acknowledge that if I 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 Institute on August 10-14, 2014. (Please limit your response to 250 words or less) By submitting this application form, the applicant certifies that all of the information and responses to questions are true and accurate to the best of his/her knowledge and belief.
Signature			Date
Name (Print/Typed)

Burden Statement

The agency collects this information under 35 U.S. C. 2(a)2 and 35 U.S.C. 2(b)11.  The information is required to obtain or retain a benefit by the public.  This collection is estimated to take 30 minutes to complete, including gathering, preparing, and submitting the completed application form to the USPTO. Time will vary depending upon the individual case. Any comments on the amount of time you require to complete this form and/or suggestions for reducing this burden, should be sent to the Chief Information Officer, U.S. Patent and Trademark Office, U.S. Department of Commerce, P.O. Box 1450, Alexandria, VA 22313‐1450. DO NOT SEND FEES OR COMPLETED FORMS TO THIS ADDRESS.

Privacy Statement

The privacy of information in this collection is covered by an existing System of Record Notice (SORN): Commerce/PAT-TM-19, Dissemination Events and Registrations (71 FR 77739).

The Privacy Act of 1974 (P.L. 93-579) requires that you be given certain information in connection with your submission of the attached form related to a USPTO application. Accordingly, pursuant to the requirements of the Act, please be advised that: (1) the general authority for the collection of this information is 35 U.S.C. 2(a)(2) and 2(b)(11); (2) furnishing of the information solicited is voluntary; and (3) the principal purpose for which the information is used by the U.S. Patent and Trademark Office is to process and/or examine your Application.

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