Form PTO/MTIP/001 MTIP Application

PTO/MTIP/001

OMB Control No.: 0651-0077

Expiration Date: 08/31/2024

Under the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless it displays a valid OMB control number.

All fields are required to complete the Master Teacher Invention Program (MTIP) application. For more information, please see the PRA Statement of Burden

Your Information

1. First name:

2. Last name:

3. Street:

4. City:

5. State or U.S. territory:

6. Zip code:

7. Telephone (where you can be reached this summer):

(xxx-xxx-xxxx)

8. E-mail address (that you have access to this summer):

9. If selected for participation, I agree to attend all sessions during the year and will make reasonable efforts, where applicable, to incorporate the lessons learned. In addition, I will cooperate in any reasonable efforts to share my experiences and outcomes with other teachers and with the Office of Education and Outreach at the United States Patent and Trademark Office (USPTO):

Yes No

10. 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 NoIf "No", Please specify other and provide details:

11. 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:

5 - Strongly agree 4 - Agree 3 - Neutral 2 - Disagree 1 - Strongly disagree

12. I have an interest in increasing student knowledge and understanding of the concepts of intellectual property, including creation and protection of intellectual property:

5 - Strongly agree 4 - Agree 3 - Neutral 2 - Disagree 1 - Strongly disagree

13. Please check all STEM or STEM-related* courses you have taught during the 2021-2022 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

Career and Technical Education

Chemistry

Computer Science

Computer-Aided Design

Creative Thinking Design Thinking

Engineering

Geometry

Graphic Design

Industrial Design

Intellectual Property

Invention Education

Materials Science

Mechanics

Other Math Course Physics

Rapid Prototyping

Robotics

Technology

Trigonometry

Visualization

Welding/Shop

Woodworking

Other

if other provide details:

14. Please check all STEM or STEM-related* courses you will teach during the 2022-2023 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

Career and Technical Education

Chemistry

Computer Science

Computer-Aided Design

Creative Thinking Design Thinking

Engineering

Geometry

Graphic Design

Industrial Design

Intellectual Property

Invention Education

Materials Science

Mechanics

Other Math Course Physics

Rapid Prototyping

Robotics

Technology

Trigonometry

Visualization

Welding/Shop

Woodworking

Other

if other provide details:

15. 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 Research/Citizen Science Programs Science Fair Projects

Scouting

4-H

Other

if other provide details:

16. 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:

5 - Strongly agree 4 - Agree 3 - Neutral 2 - Disagree 1 - Strongly disagree

17. 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 into your classroom practice: (Check all that apply)

Project-based learning

Problem-based learning

Engineering design processes

Project lead the way

Case-based learning

Collaborative learning Invention Education

Genius Hour

5 E (or 7E) approach to learning

Culturally responsive instruction

Maker education

Other

if other provide details:

18. Identify any past awards or training programs that you have participated in: (Check all that apply)

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:

Other If other provide details:

19. Were you able to take any of your knowledge from past programs back to your students or classroom? :

Yes No

20. Please share any additional information that may be relevant to your interest in participating. (Please limit your response to 250 words or less). Please include your interest, experience, and motivation for applying to MTIP. For more information, please visit our FAQ page:

21. Please share your thoughts on the following topics:

Your approach to teaching teachers and student engagement

Why you are interested in participating in the MTIP

How you engage students in a creative learning environment

How you plan to use what you learn about invention and intellectual property education

Explain (Please limit your response to 250 words or less)

Your school's information

22. School name:

23. School district or county:

24. School website:

25. Street:

26. City:

27. State or U.S. territory:

28. Zip code:

29. Name of approving principal or administrator:

30. Contact number of approving principal or administrator:

(xxx-xxx-xxxx)

31. E-mail address of approving principal or administrator:

32. My school principal or administrator/superintendent has endorsed my application. Endorsement means my principal or administrator is aware of my application to this program and has agreed to support my efforts. 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 and with the USPTO:

Yes No

33. I understand that my principal or administrator may be contacted to verify awareness of my application to participate in this program:

Yes No

34. 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

PRA Statement of Burden

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 valid OMB Control Number. The OMB Control Number for this information collection is 0651-0077. Public burden for this form is estimated to average 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. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden to the Office of the Chief Administrative Officer, United States Patent and Trademark Office, P.O. Box 1450, Alexandria, VA 22313-1450 or email [email protected].

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 http://www.osec.doc.gov/opog/PrivacyAct/SORNs/pat-tm-19.html (http://www.osec.doc.gov/opog/PrivacyAct/SORNs/pat-tm-19.html).