Please fill out the following form as completely as you can. NASA requires that we provide detailed information on each NASA funded activity. This data helps us determine how well we're doing in achieving the goals for the project. Your responses are not shared outside the Nevada System of Higher Education except with NASA. Completion of this form is required at the end of each semester that you participate in the project, however there may be times that reports are required earlier, depending on NASA's requirements. 

If you have any questions, you may contact Gibran Chavez-Gudino at gibran@nshe.nevada.edu or Alice Ward at alice_ward@nshe.nevada.edu.

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* 1. Today's Date

Date

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* 2. CONTACT INFORMATION

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* 3. Current Address

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* 4. Permanent Address

ACADEMIC/ CAREER INFORMATION

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* 5. Current semester of enrollment (what semester is this?):

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* 6. What institution(s) are you enrolled at this semester and how many credits are you taking (at each of them)?

  Are you currently enrolled at this institution? How many credits are you taking at this institution? (If you are not enrolled then choose "0")
CSN
DRI
GBC
NSC
TMCC
UNLV
UNR
WNC

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* 7. What is your declared major/program? (e.g. A.A. in English, A.S. in Biological Science)

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* 8. Academic institution:

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* 9. Major/ Minor:

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* 10. What is the highest level of school you have completed or the highest degree you have received?

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* 11. What semester(s) did you participate in Community of Practice?

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* 12. How did you hear about the Community of Practice program?

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* 13. How many credits are you enrolled in for next semester?

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* 14. Grade Level:

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* 15. Anticipated Graduation Date (Associates Degree)

Date

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* 16. What are your educational or career plans for after completing your AS degree?

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* 17. Have you changed your educational or career plans as a result of participating in this project?

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* 18. Will you be attending a different educational institution next year?

PROJECT INFORMATION

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* 19. Project Duration

Date
Date

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* 20. Please provide a summary description of your activity on this project including any anecdotal stories or highlights.

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* 21. During this project, were you engaged in research activities (such as lab or field work)?

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* 22. Did this activity/project provide you the opportunity to contribute to any publications?

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* 23. Did this activity/ project provide you the opportunity to travel?

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* 24. Did this activity/project provide the opportunity for you to participate as a presenter in any talks, poster presentations, or meetings?

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* 25. Did participation in this project make a significant impact on your current or future education/career choices?

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* 26. Did you receive funding related to your participation in this project? (such as scholarships, mini-grants, wages, funding to attend a special course or conference, travel awards, etc.)

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* 27. Approximately how many hours did you spend participating in the Community of Practice program per semester? (Explain as follows for each semester participated: Spring 2015: 60 hours)

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* 28. What is the "next step" you have taken after participating in Community of Practice?

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* 29. Anecdotal Information:

FACULTY MENTOR

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* 30. Please provide the following information regarding the primary faculty member you worked with on this project.

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* 31. Please provide any comments/ feedback that would help us improve this student opportunity in the space below.

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