0651-0077 PTO/MTIP/001 MTIP Application Form

Application for USPTO’s Master Teacher of Invention and Intellectual Property Education Program

The Master Teacher of Invention and Intellectual Property Education Program (MTIP) trains teacher-leaders to provide IP and invention-focused professional development opportunities to fellow educators in their communities and across the nation. For more information, please visit the MTIP website.

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PTO/MTIP/001
OMB Control No. 0651-0077

Expiration Date: XX/XX/XXXX

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. For more information, please see the PRA Statement of Burden.

All fields are required to complete the MTIP application.

Your Information

1. First name:

2. Last name:

3. Telephone number (Format: xxx-xxx-xxxx):

4. Email address:

Your school's information

5. School name:

6. School district or county:

7. School website:

8. Street:

9. City:

10. State or U.S. territory:
           

11. Zip code:

12. I have been employed as a full-time/part-time, licensed or certified teacher/instructional specialist or coach in an elementary, middle, or high school (public or private) in the United States for at least three years:  Yes   No

If "No," please provide details: 

13. I am currently teaching: Elementary School Middle School High School

14. Please select all subjects you have taught: (Check all that apply)

Mathematics: Algebra, Calculus, Geometry, Trigonometry, other math courses

Science: Biology, Chemistry, Physics, Botany, Materials Science

Technology: Computer Science, Computer-Aided Design, Technology, Graphic Design, Industrial Design, Rapid Prototyping

Career and Technical Education

Engineering: Engineering, Mechanics, Robotics, Design Thinking

Business or Entrepreneurship

General STEM/STEAM education

Other: Please specify any other STEM or STEM-related subjects you have taught.

 

15. Please select any informal or formal educational programs where you have taught or mentored students in areas related to 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
 Scouting
 4-H

 STEM/STEAM Club
Other

If other, provide details: 

16. Why are you interested in becoming a Master Teacher of Invention and Intellectual Property Education? Please include any additional information you would like us to consider with your application. Please limit your response to 250 words or less.

 

17. Describe your approach to teaching and how you engage your students in a creative learning environment. Please include any specific experience with implementing invention education. Please limit your response to 250 words or less.

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)
 International Society for Technology in Education
 International Technology and Engineering Educators Association
 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. How did you hear about MTIP? (Check all that apply)

USPTO website

 Social Media (e.g., Facebook, Twitter, LinkedIn)

Which social media channel? _____________________________________
USPTO webinar
Email announcement

Master Teacher of Invention and Intellectual Property Education Program (MTIP)

National Summer Teacher Institute (NSTI) alumni
PAEMST network

Albert Einstein Distinguished Educator network

Government agency

Identify program or agency: ________________________________________________
Teacher conference

Identify conference: __________________________
Attendance at a previous USPTO event

Other (please specify) _________________________________________________________

20. I have read and agree to abide by the MTIP terms and conditions. Yes   No

 

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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/survey is estimated to average X 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 Master Teacher of Invention and Intellectual Property Education Program. 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.