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.

Question Title

* 1. Today's Date:

Date

Question Title

* 2. Name:

Question Title

* 3. Institution:

Question Title

* 4. Department:

Question Title

* 5. Title:

Question Title

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

Question Title

* 8. Primary role on this project:

Question Title

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

DEMOGRAPHICS:
CONTACT INFORMATION:

Question Title

* 15. Current Address:

Question Title

* 16. Email:

Question Title

* 17. Phone:

ACADEMIC/CAREER INFORMATION:

Question Title

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

Question Title

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

Question Title

* 20. Space Grant Award History:

T