PTO/NSTI/001
OMB Control No. 0651-0077
Expiration Date: 05/31/2021
PRA Statement of Burden
The United States Patent and Trademark Office (USPTO) is using this application form to apply to the National Summer Teacher Institute. This application is voluntary, includes 30 questions and should take around 30 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.
All fields are required in order to complete the NSTI application
1. Applicant's First Name:
2. Applicant's Last Name:
3. School Name:
4. School District or County:
5. School Website:
6. School Address:
7. City:
8. State or U.S. Territory:
State SelectorAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPuerto RicoGuamU.S. Virgin IslandsAmerican SamoaNorthern Mariana IslandsU.S. Military/DoDEA Schools
9. Zip Code:
10. Applicant's Address:
11. City:
12. State or U.S. Territory:
State SelectorAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPuerto RicoGuamU.S. Virgin IslandsAmerican SamoaNorthern Mariana IslandsU.S. Military/DoDEA Schools
13. Zip Code:
14. Telephone (where you can be reached this summer):
(xxx-xxx-xxxx)
15. E-mail Address (that you have access to this summer):
16. Name of Approving Principal or administrator:
17. Contact Number of Approving Principal or Administrator:
(xxx-xxx-xxxx)
18. E-mail Address of Approving Principal or Administrator:
19. If selected for participation in the NSTI, I agree to attend all sessions beginning on July __ 2021 and ending on July ___ 2021 and will make reasonable efforts, where applicable, to incorporate the lessons learned during the Institute in my classroom and school district/county during the ________ 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
20. I have been employed as a full-time, licensed or certified teacher in an elementary, middle or high school (public or private) in the United States for at least three years:
Yes No
If "No", Please Specify Other:
21. 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: (will provide a scale for this question: 1-5)
Yes No
22. I have an interest in increasing student knowledge and understanding of the concepts of intellectual property, including creation and protection of intellectual property: (will provide a scale for this question: 1-5)
Yes No
23. 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: (will provide a scale for this question: 1-5)
24. 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
Industrial Design
Intellectual Property
Invention Concepts
Materials Science
Mechanics
Other Math Course
Physics
Rapid Prototyping
Robotics
Technology
Trigonometry
Visualization
Welding/Shop
Woodworking
Career and Technical Education
Identify specific content area:
Other
if other provide details:
25. 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
Industrial Design
Intellectual Property
Invention Concepts
Materials Science
Mechanics
Other Math Course
Physics
Rapid Prototyping
Robotics
Technology
Trigonometry
Visualization
Welding/Shop
Woodworking
Career and Technical Education
Identify specific content area:
Other
if other provide details:
26. 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: Invention, Innovation, Making, or Entrepreneurship. (Check all that apply)
Computer Science Club
Entrepreneurship Club
Invention Competitions
Inventors Club
Making/Design/Do-It-Yourself (DIY)projects
Robotics Programs
Science Fair Projects
Scientific Research
Scouting
4-H
Other if other provide details:
27. Identify forms of pedagogy that you have utilized in your classroom which may enhance your ability to bring knowledge and pedagogy that you will learn at NSTI, into your classroom practice:
Choose all that apply.
Project Based Learning
Problem Based Learning
Engineer and Design Processes
Project Lead the Way
Case Based Learning
Collaborative Learning
Genius Hour
5 E (or 7E) approach to learning
Culturally responsive instruction
Maker Education
Other (if other, provide details)
28. Identify any past awards/training programs that you have participated in:
National Science Teachers Association (Regional or National)
State Professional Association Conferences (relevant content)
ISTE
ITEEA
Research Experience for Teachers
Lemelson-MIT Invention Programs
Invention Convention
Science Congress
Discovery Education STAR Educator Program
Albert Einstein Distinguished Educator Fellowship
Department of Education Fellowship Program
Presidential Award for Math and Science Teachers Program
Henry Ford Teacher Innovator
Master Teacher (explain)
29. Were you able to take any of your knowledge from past programs back to your students or classroom?
Yes No
30. My school principal or administrator/superintendent has endorsed my application to the USPTO National 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
31. I understand that my principal or administrator may be contacted to verify awareness of my application to participate in this program:
Yes No
32. 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
33. Please share any additional information that may be relevant to your interest in participating in the USPTO National Summer Teacher Institute in July _(insert date and year)________. (Please limit your response to 250 words or less):
34. Please share your thoughts on any one of the following topics:
your approach to teaching and student engagement
why you are interested in attending the NSTI
how you engage students in a creative learning environment
how you plan to use what you learn about invention and intellectual property education and how this will add value to your classroom
Privacy Act Statement
The authority for the collection of this information is 5 U.S.C. § 301, 35 U.S.C. § 2, and E.O. 12862. The information you provide will be used to verify your identity and administer participation in the National Summer Teacher Institute. 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-19, Dissemination Events and Registrations, available at https://www.uspto.gov/uspto-systems-records-notices
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Ward, Joyce |
| File Modified | 0000-00-00 |
| File Created | 2021-05-24 |