Faculty/Participant Profile - Community of Practice

PROFILE

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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 Holguin, Program Coordinator, at stephanie_holguin@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:

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. Primary role on this project:

Faculty Mentor

Administrative Support

Campus Lead

Guest Speaker

Other (please specify)

DEMOGRAPHICS:

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* 8. Gender:

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* 9. Race:

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* 10. Ethnicity:

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* 11. Disability:

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* 12. Citizenship:

CONTACT INFORMATION:

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* 13. Current Address:

Address

City

State

ZIP

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* 14. Email:

Primary Email Account:

Secondary Email Account:

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* 15. Phone:

Primary Phone Number:

Cell Phone Number:

ACADEMIC/CAREER INFORMATION:

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

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

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* 18. Are you currently engaged in any research projects? (If yes, please describe)

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* 19. 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: