I-Corps Record of Participation

All information you provide in this form is protected under the National Science Foundation Act of 1950 and the Privacy Act of 1974, specifically, under two systems of records: NSF-12, “Fellowships and Other Awards” and NSF-50, “Principal Investigator/Proposal File and Associated Records.” Both systems include records maintained by NSF as a result of applications for financial support and subsequent evaluation of applicants and their proposals. System 12 contains records on individuals applying or nominated for and/or receiving NSF support, either individually or through an academic institution, including fellowships or other awards to individuals of various types. System 50 contains records on Individuals (known as principal investigators) who have requested and/or received research or other support from NSF, either independently or through an academic or other institution.

The primary purpose of collecting this information is to enable NSF to identify outcomes of projects funded under NSF awards for use in management evaluation and for reporting to the Administration and Congress, especially under the Government Performance and Results Act, 5 U.S.C. 306 and 39 U.S.C. 2801–2805. In addition, it also helps NSF to evaluate the progress and results of NSF-funded projects for program management, evaluation or reporting.

Data collected may be merged with other data files to carry out statistical studies. Disclosure may be made for this purpose to NSF contractors and collaborating researchers, and other Government agencies, and qualified research institutions and their staffs for the purpose of analyzing data, preparing scientific reports and articles and selecting samples for a limited number of carefully defined follow-up studies. NSF contractors are subject to the provisions of the Privacy Act. The results of such studies are statistical in nature and do not identify individuals.

As published in Federal Register Notice, 79 FR 76398, information collected under System 12 maybe disclosed to: 1) Members of Congress in response to an inquiry from the congressional office made at the request of that individual, 2) Department of Justice or the Office of Management and Budget under the Freedom of Information Act and the Privacy Act, 3) NSF’s legal representatives and other outside counsel, where the agency is a party in litigation or has an interest in litigation, 4) General Services Administration (GSA) and the National Archives and Records Administration (NARA) under the authority of 44 U.S.C. 2904 and 2906, 5) Appropriate agencies, entities, and persons in response to an actual or suspected compromise or breach of personally identifiable information, 6) Department of Justice or other agencies in the event of a pending court or formal administrative proceeding, 7) Government agencies and other entities authorized to perform audits of the agency and its activities, 8) Appropriate Federal, state, or local law enforcement agencies in cases when NSF becomes aware of an indication of a violation or potential violation of civil or criminal law or regulation, and 9) News media and the public when a matter has become public knowledge and/or when the Office of Director determines that there exists a legitimate public interest in the disclosure of the information.

Per the Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity risks through screening of the federal information systems that transmit your data. Information collected under this form will be kept confidential. Any information released publicly (such as statistical summaries) will be in a form that does not personally identify you or other respondents. Your response is voluntary and failure to provide some or all of the requested information will not in any way adversely affect you.

I-Corps Hubs - Record of Participation

Pursuant to 5 CFR 1320.5(b), an agency may not conduct or sponsor, and a person is not required to respond to an information collection unless it displays a valid OMB control number.  The OMB control number for this collection is 3145-XXXX.  Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions.

Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing this burden, to: Suzanne H. Plimpton, Reports Clearance Officer, National Science Foundation, 2415 Eisenhower Ave., Suite W18200, Alexandria, VA  22314; telephone (703) 292-7556; or send email to [email protected] .

*Required Field

Part I. Logistical Information. Please use the information provided by the Hubs upon completion of the I-Corps Hubs Program to fill out the following fields.

* 1-1. Name of the I-Corps Hub:

* 1-2. Name of your I-Corps Team:

* 1-3. I-Corps Team Numerical Identifier (4-digit):

* 1-4. Month and Year of Program Completion: Month Year

Part II. About the Participant. This section asks for your name, job title, contact information, gender, race, ethnicity, disability and veteran status.

*Required Field

* 2-1. Name (Last Name, First Name, Middle Initial) *:

* 2-2. Current Job Title*:

* 2-3. Email address*:

2-4. Are you male or female?

• Male

• Female

• Prefer not to answer

2-5. Are you Hispanic or Latino? (Select one)

• No, I am not Hispanic or Latino

• Yes, I am Mexican or Chicano

• Yes, I am Puerto Rican

• Yes, I am Cuban

• Yes, I am Other Hispanic or Latino

• Prefer not to answer

2-6. What is your racial background? (Select one or more)

• American Indian or Alaska Native

• Native Hawaiian or Other Pacific Islander

• Asian

• Black or African American

• White

• Prefer not to answer

2-7. The following questions are designed to help us better understand the educational and/or career paths of individuals with specific functional limitations. What is the USUAL degree of difficulty you have with…

Mark one (X) in each row.

	NONE	SLIGHT	MODERATE	SEVERE	UNABLE TO DO	PREFER NOT TO ANSWER
SEEING words or letters in ordinary newsprint (with glasses/contact lenses, if you usually wear them)
HEARING what is normally said in conversation with another person (with hearing aid, if you usually wear one)
WALKING without human or mechanical assistance or using stairs
LIFTING or carrying something as heavy as 10 pounds, such as a bag of groceries
CONCENTRATING, REMEMBERING, or MAKING DECISIONS because of a physical, mental or emotional condition

2-8. Have you ever served on active duty in the U.S. Armed Forces, Reserves, or National Guard?

Select one.

• Never served in the military

• Only on active duty for training in the Reserves or National Guard

• Currently on active duty

• On active duty in the past, but not now

• Prefer not to answer