Form NIST-1103 Teacher Application for the NIST Summer Institute for Mi

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

NIST-1103
(REV. 12-2017)
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., Kate Rimmer, via email at
[email protected] or telephone (301) 975-3651.
Privacy Act Statement
Authority: 15 U.S.C. § 278g-1(e) and 15 U.S.C. § 278g-2a.
Purpose: The National Institute for Standards and Technology (NIST) Summer Institute and the NIST RET are two competitive financial
assistance (cooperative agreement) programs that offer middle school (Grades 6-8) science teachers an opportunity to participate in handson activities, lectures, tours, visits, or scientific research with scientists and engineers in NIST laboratories. The aim is to encourage them to
inspire students to pursue careers in science, technology, engineering, and mathematics (STEM) fields.
Routine Uses: NIST will use the information collected to perform the requisite reviews of the applications to determine eligibility, to make
funding decisions, and to meet programmatic requirements, as well as compliance with 15 C.F.R. Part 14. Disclosure of this information is
also subject to all the published routine uses as identified in the Privacy Act System of Records Notices: NIST-1: NIST Associates.
Disclosure: Furnishing this information is voluntary. When you submit the form, you are indicating your voluntary consent for NIST to use
of the information you submit for the purpose stated.

Check the applicable program:

NIST Summer Institute

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. Yes
b. No

NIST RET

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 the Federal
Funding Opportunity (FFO) or if nominated for the NIST RET, will you be able to commit six (6) full continuous weeks to
participate in the NIST RET from 8:30 a.m. to 5 p.m. Monday through Friday during the summer?
a. Yes
b. 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.
Additional Grades
(Select all that apply)

Primary Grade
(Select One)
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.
Additional Grades
(Select all that apply)

Primary Grade
(Select One)
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. 12-2017)

Science

Education

Science
Education

Other

None

18. 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

No

Biology
Earth Science
Space Science
Physics
Chemistry
Weather

Other (specify):

19. Which of the following professional development activities have you participated in during the past three (3) years? (Mark
all that apply.)
a.

Learning content knowledge related to science

b.

Learning content knowledge not related to science

c.

Selecting and adapting instructional material

d.

Using research to inform curriculum with standards

e.

Learning strategies for aligning curriculum with standards

f.

Working with diverse and/or minority students, special education students, and/or students with limited English
proficiency

g.

Developing leadership skills in working with peers

h.

Developing skills in working with parents, school boards, or other outside of the school

i.

Using technology in instruction

j.

Learning how to use data and statistics

k.

Other (specify):

NIST-1103 (REV. 12-2017)

20. 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)

21. How did you learn about the NIST Summer Institute or NIST RET program? (Mark one response.)
a.

Noticed an open invitation and decided to apply.

b.

Encouraged by a former NIST Summer Institute or NIST RET participant and decided to apply.

c.

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).

d.

Encouraged/recruited/designated specifically by my school principal.

e.

Encourage/recruited/designated by local leadership council/curricular committee or professional development
program or organization.

f.

Other (Specify):

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

NIST-1103 (REV. 12-2017)

23. For RET only, please describe one lesson or concept that you learned about at NIST that you have implemented in
your classroom.

NIST-1103 (REV. 12-2017)

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. Please discuss some
scientific ideas you would like to bring home to your students.

*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. 12-2017)