Day 1 Roadcheck

Complete the following form and click on SUBMIT to confirm your registration.

You must complete this form in one sitting - you cannot save a portion and return to fill out the rest later. We encourage you to compose your answers to the longer questions in a word processor and to copy/paste the resulting text into this form.

First Name:

Last Name:

Name of Institution:

Email Address:

Confirm Email Address:

(Please Note: Your email address is what we use to track your application and participation in the workshop. Be sure to use the same email address in all forms relating to your workshop participation. This email will also be our primary means of communication with you.)

Phone Number (this information is only used to contact you if there are issues that arise during the workshop.)

Course Information
What course will you be working on during the workshop? Please list only one.

What department is the course taught in, and at what level (e.g., intro)?

What is the approximate enrollment for the course you will be working on?

Is this a new course, or are you redesigning a course that you have previously taught?

When will the course you are designing/redesigning be taught?

Is any portion of your course delivered on line? If so, please describe.

Briefly describe the goals for the course as you see them at the moment.

In general, what do you consider to be the characteristics of a strong assignment/activity?

What topic(s) would you particularly like to see addressed during the workshop?

Research Release

I have read the Description of the Research Project and Implications for Participation (opens in a new window) or it was read to me. I know the possible risks and benefits. I know that being in this study is voluntary. I choose to be in this study. I know that I can withdraw at any time. I am at least 18 years of age and voluntarily grant permission for the described release and use of notes and comments regarding me in the workshop.

Please select one of the following choices to indicate your level of desired participation in the study:

I consent to participate in ALL aspects of this study. My pre-workshop information, all workshop information, and follow-on workshop information can be used in this study, and I agree to participate in a follow-up interview in approximately 2-6 months which will be audio taped. Video, still images, and audio collected at the workshop may also be used in the research project.
I consent to participate in some, but not all, aspects of this study. Please discuss with us the aspects in which you do NOT consent to participate.

Workshop Product Release

In confirming my registration for this workshop, I agree that any audio recording or images (still or video) made of me during the workshop may be used on the project website, in printed project publications, and in materials developed by the project. I further agree that my contributions to creative works that emerge from workshop activities (e.g., discussions on the email list, contributions to the web page, summaries of group discussion, etc.) may be used by the workshop series, PIs, and conveners for development of future workshop materials, for scholarly reports, and for promotion of the workshop series. Attribution for original contributions will be made whenever possible.

I also accept responsibility to cover any costs incurred should I withdraw from participation in the workshop after May 15, 2010. I understand that arrangements have been made on my behalf that have associated real costs (e.g. logistics, materials), and in many cases, my early confirmation has secured a place that has been denied to other interested colleagues. Exceptions will only be made in cases of extreme personal hardship.

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