SURF Fellow Housing Application

20XX SURF Program Housing Survey
OMB Control #0693-0084
Expiration Date: 05/31/2022

* 1. Which Lab will you be working in this summer?
CNST-Center for Nanoscale Science & Technology
CTL-Communications Technology Laboratory
EL-Engineering Laboratory
ITL-Information Technology Laboratory
MML-Material Measurement Laboratory
NCNR-NIST Center for Neutron Research
PML-Physical Measurement Laboratory
Other (Standards Coordination Office or Technology Partnerships Office)
I don't know!

* 2. Do you require housing for the SURF Program?
Yes
No

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20XX SURF Program Housing Survey

* 3. What is your first name?

* 4. What is your last name?

* 5. What is your sex?
Female
Male

* 6. What is your email address?

* 7. What is the name of the school you attended in the Spring 20XX ?

* 8. Are you an Early Bird/Night Owl? (Required if requesting housing)
I like to stay up late.
I like to go to bed early.
I do not have a preference.

9. What is your opinion of neatness? (Required if requesting housing)
A neat, clean environment is a priority to me.
I strive to maintain a neat, clean environment, but it is not my priority.
A clean state of disorder is the norm for me.

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* 10. If you are requesting housing, please tell us which preferences are the most important to you (1=early
bird/night owl, 2=neatness, 3=other preferences).
1-2-3
1-3-2
2-1-3
2-3-1
3-2-1
3-1-2

11. List any other housing preferences, concerns, or special needs:
NOTE A:
Your application form stated that you should expect to share a room with another student.
Unless there is a certifiable reason (i.e. medical reason which includes doctor's note) why you need a
single, requests for singles will not be responded to or acknowledged.
NOTE B:
If you have a preferred roommate, identify that person by name and YOU MUST ask them to identify you
as a preference as well. The preferred roommate must be of the same gender and participating in the
program for the same duration ( for example a 9-week participant cannot request a 11-week participant as
a preferred roommate).
NOTE C:
This isn't a Tender profile so don't add things like "I don't want a roommate that snores" or "I only want
roommates that are happy all the time", but if something is important ("I am a vegetarian" and "I have
allergies" are good examples), please list it.

12. Do you have a preferred roommate? If so, please tell us his/her name.
NOTE: your preferred roommate must also mention your name on his/her survey.

* 13. Smoking (FYI, all suites are non-smoking)
I am a smoker.
I do not smoke.
I prefer to not live with a smoker.

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* 14. I will need housing for:
Note: Participants needing housing after August XX, 20XX, must make his/her own arrangements.
11 weeks (approximately May XX-August XX, 20XX)
9 weeks (approximately June X-August XX, 20XX)

Other (please specify)

15. Is there anything you would like to share with us which was not previously addressed?

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a
penalty for failure to comply with an information collection subject to the requirements of the Paperwork Reduction Act of
1995 unless the information collection has a currently valid OMB Control Number. The approved OMB Control Number for
this information collection is 0693-0084. Without this approval, we could not conduct this survey. Public reporting for this
information collection is estimated to be approximately 30 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information
collection. All responses to this information collection are required to obtain benefits. Send comments regarding this burden
estimate or any other aspect of this information collection, including suggestions for reducing this burden to the National
Institute of Standards and Technology, 100 Bureau Drive, Gaithersburg, MD 20899, Attn: Brandi Toliver;
[email protected].

Privacy Act Statement
Authority: 15 U.S.C. § 278g-1(a)
Purpose: The National Institute for Standards and Technology (NIST) hosts the Summer Undergraduate Research Fellowship
(SURF) which provides an opportunity for the NIST laboratories to encourage outstanding undergraduate students to pursue
careers in science and technology. This information collection will serve as the housing application for the program.
Routine Uses: NIST will use the information collected to perform the requisite reviews of the applications to determine eligibility,
and to meet programmatic requirements. 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.

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