Form 3135-0098 Panelist Profile Data Collection

1

Name
Salutation
Dropdown with options:
•
•
•
•
•
•

Dr.
Mr.
Mrs.
Ms.
Prof.
Rev.

First Name fillable box
Middle Name fillable box
Last Name fillable box
Preferred Name fillable box
Suffix
Dropdown with options:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

II
III
IV
CPA
DDS
DO
Esq
JD
Jr
LLD
MD
PhD
Ret
RN
Sr

Email
Primary Email fillable box
Alternative Email fillable box

Occupation fillable box

2

Addresses
Work Street Address 1 fillable box
Work Street Address 2 fillable box
Work Street Address 3 fillable box
Work City fillable box
Work State dropdown
Work Postal Code fillable box
Work Country dropdown
Home Street Address 1 fillable box
Home Street Address 2 fillable box
Home Street Address 3 fillable box
Home City fillable box
Home State dropdown
Home Postal code fillable box
Home Country dropdown

Phone Number(s)
Phone Number(s) fillable boxes

Categories
A. Panelist Tags
•
•

Federally registered lobbyist: Cannot serve on NEA panels
Layperson: You are not engaged in the arts as a profession, or your primary job is not in the arts

B. Panelist Ethnicity (Optional/Pick One. Note: All federal government agencies must use these
standards that are issued by the U.S. Office of Management and Budget.)
•
•

Hispanic or Latina/o: A person of Hispanic, Latino, or Spanish origin; may be of any race.
Not Hispanic or Latina/o

C. Panelist Race (Optional/You may choose more than one. Note: All federal government agencies must
use these standards that are issued by the U.S. Office of Management and Budget.)
•

American Indian or Alaskan Native: A person with origins in the original peoples of N./S.
America.

3
•
•
•
•

Asian: A person with origins in the original peoples of the Far East/SE Asia/Indian
subcontinent.
Black or African American: A person with origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander: A person w/origins in original peoples of
HI/GU/Samoa/Pacific Islands
White: A person with origins in the original peoples of Europe, the Middle East, or North Africa.

D. Panelist Sex (Optional/Pick One. Note: All federal government agencies must use these standards
that are issued by the U.S. Office of Management and Budget.)
•
•

Female
Male

E. Panelist Disability. Optional. Select your disability, if applicable. Let your staff contact know if you will
need any access accommodations during your panel service.
•
•
•
•

Hearing
Mobility
Other (with optional fillable box)
Vision

F. Other Panelist Language(s). Optional. Select any non-English language(s) in which you are fluent
(reading and oral comprehension).
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

American Sign Language
Arabic
Chinese
Danish
Dutch
Farsi
French
German
Greek
Hawaiian
Hebrew
Hindi
Indonesian
Italian
Japanese
Korean
Native language
Other (with optional fillable box)
Portuguese
Russian
Spanish
Swahili

4
•
•
•
•

Swedish
Tagalog
Turkish
Vietnamese

G. Panelist Organization Type. Select types of organizations with which you have had arts experience.
You may choose more than one box.
•
•
•
•
•
•
•
•
•

Arts organization
Arts service organization
Educational organization or school
Funding organization
Local arts agency
None of the above
Other (with optional fillable box)
Regional arts organization
State arts agency

H. Panelist Field. You may choose more than one. Note: If you are a layperson, make selections that
most closely represent the areas of arts expertise/knowledge that you can bring to a panel.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Arts Administration
Arts Education
Arts Presenting
Artist Communities
Dance
Design
Education
Folk & Traditional Arts
International Activities
Literature
Local Arts Agencies
Media Arts
Multidisciplinary Arts
Museum
Music
Musical Theater
Opera
Other (with optional fillable box)
Research
Theater
Visual Arts

I. Panelist Role. You may choose more than one. Note: If you are a layperson, make selections that
most closely represent the areas of arts expertise/knowledge that you can bring to a panel.

5
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Active or Retired Military
Actor
Administrator/Manager
Architect
Art Historian/Scholar
Artist
Artist in Residence
Artist Representative
Artistic Director/Staff
Arts Organization Staff
Arts/Cultural Organization Board Member/Trustee
Arts/Cultural Organization Volunteer
Assistant/Deputy Director
Choreographer
Community Media or Broadcast Staff
Composer/Arranger
Conductor
Consultant
Creative Technologist
Critic
Curator
Curriculum Specialist
Dancer
Designer
Digital Artist
Director
Dramaturg/Literary Manager
Editor
Education Director/Staff
Educator
Ethnomusicologist
Executive Director/President
Experience Designer
Filmmaker/Videomaker
Film Exhibitor or Distributor
Folklorist
Former Board Member
Former Staff Member
Instrumentalist
Landscape Architect
Librarian
Maker
Media Artist

6
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Other (with optional fillable box)
Patron (arts)
Planner
Playwright
Poet
Presenter
Producer
Program Director/Staff
Researcher/Evaluator
School Board Member
School Teacher/Arts Specialist
Singer/Vocalist
Teaching Artist
Translator
Writer

J. Panelist Specialization. You may choose more than one. Note: If you are a layperson, make
selections that most closely represent the areas of arts expertise/knowledge that you can bring to a
panel.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

African or African-American Arts/Cultures
Architecture
Artist Communities
Arts
Arts Center
Asian or Asian American Arts/Cultures
Audio/Radio/Podcast
Ballet
Chamber Music
Choral
Circus Arts
Classical
Community Development/Planning
Contemporary Art
Contemporary or Modern Dance
Crafts
Creative Nonfiction
Cultural Exchange
Curriculum Development
Dance
Digital Arts
Digital Preservation
Digital Technology

7
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Disability Arts
Disability Access
Documentary Film
Education
Environmental Design
Ethnomusicology
Evaluation/Assessment
Fashion Design
Festivals
Fiction
Film/Video
Film Festivals
Folk Arts/Traditional Arts
General Director
Generalist
Grants Management
Graphic Design
Internet Art
Immersive Experiences
Hip Hop
Historic Preservation
Jazz
Landscape Architecture
Latino/Latino-American arts/cultures
Long-Range Planning
Making
Media Arts
Middle Eastern arts/cultures
Multidisciplinary
Music
Musical Theater
Native American/Alaskan Native arts/cultures
Open Source Software
Orchestral/Symphonic
Organizational/Institutional Development
Other (with optional fillable box)
Outdoor Drama
Pacific Islander Arts/cultures
Painting
Performance
Performing Arts
Photography
Physically Integrated Arts

8
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Playwriting
Poetry
Post-secondary School
Pre-kindergarten/Early Childhood
Preservation
Professional/Staff Development
Public Art
Public Broadcasting
Publications
Puppetry
Radio
Rural
Rural Design
Sculpture
Secondary School
Site Specific Work
Slam Poetry
Sound Art
Systems Change
Tap/percussive dance
Translation
Teaching
Television
Urban Design/Planning
Video Games
Virtual or Augmented Reality
Visual Artists’ Organizations

Biography
Fillable box, 750 characters max.
ORCID iD Fillable box

Social Security Number
If you are serving on a panel, and would like to receive payment for your work, you will enter your
social security number here. However, you may wait to provide this information until your service is
confirmed.
If your social security number is on record for the purposes of reporting payments or honorarium to the
IRS, the last four digits are displayed here.
Click Edit SSN to modify this value. Upon saving, only the last four digits will be displayed.

9
Social Security Number: Fillable box
OMB No. 3135-0098 Exp. TBD
Paperwork Reduction Act Statement
The public reporting burden for this collection of information is estimated to average 10 minutes per
response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Note: You are
not required to respond to the collection of information unless it displays a currently valid Office of
Management and Budget (OMB) control number.
Privacy Act
The following notice is furnished in accordance with the Privacy Act of 1974, 5 U.S.C. 552a:
This information is solicited under the authority of the National Foundation on the Arts and the
Humanities Act, 20 U.S.C. 951 et seq. and is used to select persons to participate in the National
Endowment for the Arts’ application review process. Disclosure of this information may be made to
members of Congress and to the general public, upon request in accordance with the Freedom of
Information Act (5 U.S. C. 552). Personal biographical data including home address, home telephone
number, and social security number will not be released and is exempt from disclosure under FOIA
exemption (b)(6).