Faculty/Participant Profile

PROFILE

Please fill out the following form as completely as you can. NASA requires that we provide detailed information on each NASA funded activity. Completion of this form is required at the beginning of your participation in this project. This data helps us determine how well we're doing in reaching a diverse group of interested participants. Your responses are not shared outside the Nevada System of Higher Education except with NASA.

If you have any questions, you may contact Stephanie Borene, Program Coordinator, at stephanie_borene@nshe.nevada.edu or Alice Ward, Project Administrator at alice_ward@nshe.nevada.edu.

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1. Today's Date:

Date:

Date

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2. Name: (Required.)

First:

Last:

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3. Institution:

CSN

GBC

WNC

TMCC

UNLV

UNR

Other (please specify)

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4. Department:

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5. Title:

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6. Are you:

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7. Which Nevada Space Grant project are you reporting on as a participant?

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8. Primary role on this project:

Project Investigator/ Lead

Faculty Mentor

Administrative Support

Campus Lead

Guest Speaker

Other (please specify)

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9. Are you currently engaged in any other research projects? (If yes, please describe the project and your role)

DEMOGRAPHICS:

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10. Gender: (Required.)

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11. Race: (Required.)

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12. Ethnicity: (Required.)

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13. Disability: (Required.)

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14. Citizenship:

CONTACT INFORMATION:

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15. Current Address:

Address

City

State

ZIP

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16. Email:

Primary Email Account:

Secondary Email Account:

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17. Phone:

Primary Phone Number:

Cell Phone Number:

ACADEMIC/CAREER INFORMATION:

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18. What is the highest degree you have obtained?

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19. Are you currently pursuing any additional degrees or certificates? If yes, please explain:

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20. Space Grant Award History:

I have received an award from Space Grant before.

I have NOT received an award from Space Grant before.

If yes, please describe the type and amount of award:

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* 1. Today's Date:

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* 2. Name: (Required.)

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* 3. Institution:

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* 4. Department:

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* 5. Title:

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* 6. Are you:

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* 7. Which Nevada Space Grant project are you reporting on as a participant?

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* 8. Primary role on this project:

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* 9. Are you currently engaged in any other research projects? (If yes, please describe the project and your role)

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* 10. Gender: (Required.)

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* 11. Race: (Required.)

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* 12. Ethnicity: (Required.)

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* 13. Disability: (Required.)

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* 14. Citizenship:

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* 15. Current Address:

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* 16. Email:

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* 17. Phone:

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* 18. What is the highest degree you have obtained?

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* 19. Are you currently pursuing any additional degrees or certificates? If yes, please explain:

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* 20. Space Grant Award History:

1. Today's Date:

2. Name: (Required.)

3. Institution:

4. Department:

5. Title:

6. Are you:

7. Which Nevada Space Grant project are you reporting on as a participant?

8. Primary role on this project:

9. Are you currently engaged in any other research projects? (If yes, please describe the project and your role)

10. Gender: (Required.)

11. Race: (Required.)

12. Ethnicity: (Required.)

13. Disability: (Required.)

14. Citizenship:

15. Current Address:

16. Email:

17. Phone:

18. What is the highest degree you have obtained?

19. Are you currently pursuing any additional degrees or certificates? If yes, please explain:

20. Space Grant Award History: