NOAA Research & Related Personal Data

OMB Number: 0648-0568, Expires XX/XX/20XX
NOAA Research & Related Personal Data
Applicant/Project Director/Principal Investigator and Co-Applicant(s)/Project Director(s)/Co-Principal
Investigator(s)
NOAA has a continuing commitment to monitor the operation of its review and award applicants. To
gather information needed for this important task, the applicant(s) should submit the requested
information for each identified applicant(s) with each proposal. Submission of the requested
information is voluntary and is not a precondition of award unless otherwise noted by the opportunity.
Any individual not wishing to submit some or all the information should check the box provided for this
purpose. Upon receipt of the application, this form will be separated from the application. This form
will not be duplicated, and it will not be a part of the review process (unless specified by the
opportunity). Data will be confidential.
Applicant

Section One: Name
Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
Nickname or Prefered Name:
Current Affiliation/Employer:

Section Two: Personal Information
Age at date of application:
Q: What is your sex?
A: (check one)
● Male
● Female

Q: What is your race and/or ethnicity?
A: (check all that apply)
● White
(For example, German, Irish, English, Italian, Polish, French, etc.)
● Hispanic or Latino
(For example, Mexican, Puerto Rican, Cuban, Salvadorian, Dominican, Guatemalan, etc.)
● Black or African American
(For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somalia, etc.)
● Asian
(For example, Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc.)
● American Indian or Alaska Native
(For example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc.)
● Middle Eastern or North African
(For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.)
● Native Hawaiian or Pacific Islander
(For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.)

Q: Disability Status Long-lasting or chronic condition (physical, visual, auditory, cognitive or mental,
emotional or other) that substantially limits one or more of your major life activities (your ability to see,
hear, or speak; to learn, remember, or concentrate):
A: (check all that apply)
● Intellectual or Learning difference
● Mobility/Orthopedic impairment
● Psychiatric condition
● Visual impairments
● Hearing impairments
● Neurological disabilities
● Chronic Illness
● Other/Self-Identify (fill in the blank)
● None
● Prefer not to answer
Q: Citizenship Status:
A:

● US Citizen
● Permanent Resident
● Other non-US Citizen
● Prefer not to answer

Section 3: Career Path Information
Q: Career Stage:
A: (check all that apply)
● Student (Currently enrolled in any degree type)
● Early Career (Up to ten years past your terminal degree)
● Mid-Career (Ten+ years past terminal degree and pre-retirement)
● Retired/Emeritus
● Other/Self-Identify (fill in the blank)
● Prefer not to answer

Q: Highest Degree Earned:
A: (check all that apply)
● High School or Equivalent
● Associate Degree
● Bachelor Degree
● Master Degree
● Doctorate Degree
● Other/Self-Identify (fill in the blank)
● None
● Prefer not to answer
Q: First Generation College Student/Graduate:
A: (check one)
● Yes (Parent(s) have NOT earned a bachelor's (or higher) degree)
● No (Parent(s) have earned a bachelor's (or higher) degree)
● Unsure (Do not know if parent(s) have earned a bachelor's
degree)
● Prefer not to answer

Q: Veteran Status:
A: (check one)
● Active Duty
● Reservist
● Veteran
● Not a Veteran
● Prefer not to answer
Q: How did you learn about this competition:
A: (check all that apply)
● Email
● Website
● College/Friend/Mentor
● Some other way (fill in the blank)
● Prefer not to answer

Public Burden Statement
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
0648-0568. Without this approval, we could not conduct this survey. Public reporting for this information
collection is estimated to be approximately 15 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 voluntary. Send
comments regarding this burden estimate or any other aspect of this information collection, including
suggestions for reducing this burden to the NOAA Office of Education, Natasha White,
[email protected].

Privacy Act Statement
Authority: The collection of this information is authorized under 5 U.S.C. 301, Departmental Regulations
and 15 U.S.C. 1512, Powers and duties of Department.
Purpose: NOAA’s Office of Education proposes to collect contact information and associated background
information of undergraduate and graduate students, as well as recent graduates, for the purpose of
tracking scholarship recipients’ academic progress, making annual financial awards, and tracking
graduate studies and career progress. This information will not be used to determine program eligibility.

NOAA Routine Uses: NOAA will use this information to evaluate and assess student data and
information for the purpose of selecting successful candidates for scholarships, fellowships and
internships, generating internal NOAA reports, and articles to demonstrate the success of its program.
Disclosure of this information is permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a) to be
shared among NOAA staff for work-related purposes. Disclosure of this information is also subject to all
of the published routine uses as identified in the Privacy Act System of Records Notice
Commerce/NOAA-14, Office of Education, Educational Partnership Program (EPP); Ernest F. Hollings
Undergraduate Scholarship Program and National Marine Fisheries Service Recruitment, Training, and
Research Program.

Obligation to Respond: Furnishing this information is voluntary; however, failure to provide information
may prevent consideration of your application for the program.