Application

Contact InformationFirst Name:

Last Name:

Institution:

Department:

Address:

City:

Select a State

Zip Code:

Phone:

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. Please double-check that you have typed it correctly.)

Question Setq1

q2

q3

q4

Demographics

Consult with the evaluation team or project evaluator before collecting this information. This section may require significant edits.

See also https://www.fastlane.nsf.gov/cgi-bin/people?5 as a reference.

The following information will be reported only in aggregate. We collect these data for our reports to the National Science Foundation, which funds this project. You are welcome to skip any of these questions if you prefer not to answer them.

Gender Identity:
If you prefer to describe, please type here:

Ethnicity (choose one):

Hispanic or Latino
Not Hispanic or Latino
I prefer not to answer

Race (select one or more, or leave all boxes blank if you prefer not to answer):
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

Disability status (select one or more):
Hearing Impairment
Mobility/Orthopedic Impairment
Visual Impairment
Other
None

Citizenship (choose one):

U.S. Citizen
Permanent Resident
Other non-U.S. Citizen

Everything below this point is just examples of what other project have choosen to collect. You should not use these questions unless it's clear a project has a defined need for the data.

Are you a veteran or member of the armed forces?

No
Veteran
Currently serving in armed forces
I prefer not to answer

Number of years of full-time teaching experience:

Number of years teaching at the college level:

Current position:

Discipline:

or Other discipline:

Will you teach next fall at an institution that serves a large number of minority students?:

Yes
No

Which of the following best describes the department or program in which you will teach next fall:

Two year college (Associate is the highest degree)
Private four-year primarily undergraduate (BS or BA is the highest degree)
Public four-year primarily undergraduate (BS or BA is the highest degree)
Masters granting (MS is the highest degree)
Doctoral granting (PhD is the highest degree)

Application

If you are accepted for the workshop, you will be asked to complete a registration form to provide us with more information.

Provenance

Reuse