NSTI Application Form

PTO/NSTI/001
OMB Control No. 0651-0077
Expiration Date: 05/31/2021

PRA Statement of Burden

The United States Patent and Trademark Office (USPTO) is using this form as an application for the National Summer Teacher Institute. This application is voluntary, includes 30 questions and should take approximately 30 minutes to complete. This information collection contains requirements subject to the Paperwork Reduction Act (PRA). Notwithstanding any other provisions of the law, no person is required to respond to, nor shall any person be subject to penalty for failure to comply with, a collection of information subject to the requirements of the PRA, unless that collection of information displays a currently valid OMB control number.

All fields are required in order to complete the NSTI application.















(xxx-xxx-xxxx)




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19. If selected for participation in the NSTI, I agree to attend all sessions during the week of July 19-23, 2021 and will make reasonable efforts, where applicable, to incorporate the lessons learned during the Institute in my classroom and school district/county during the 2021-2022 academic year. In addition, I will cooperate in any reasonable efforts to share my experiences and outcomes with other teachers at the Institute and with the Office of Education and Outreach at the USPTO:

20. I have been a full-time, licensed teacher in an elementary, middle or high school (public or private) in the United States for at least three years:

21. I have a strong desire to incorporate “making,” inventing, or innovation into the learning environment as a means for enhancing student interest in STEM learning:

22. I have an interest in increasing student knowledge and understanding of the concepts of intellectual property, including creation and protection of intellectual property:

(Check all that apply)

Algebra
Biology
Botany
Calculus
Chemistry
Computer Science
Computer-Aided Design
Creative Thinking
Design Thinking
Engineering
Geometry
Graphic Design
Industrial Design
Intellectual Property
Invention Concepts
Materials Science
Mechanics
Other Math Course
Physics
Rapid Prototyping
Robotics
Technology
Trigonometry
Visualization
Welding/Shop
Woodworking
Other

 

(Check all that apply)

Algebra
Biology
Botany
Calculus
Chemistry
Computer Science
Computer-Aided Design
Creative Thinking
Design Thinking
Engineering
Geometry
Graphic Design
Industrial Design
Intellectual Property
Invention Concepts
Materials Science
Mechanics
Other Math Course
Physics
Rapid Prototyping
Robotics
Technology
Trigonometry
Visualization
Welding/Shop
Woodworking
Other

 

(Check all that apply)

Computer Science Club
Entrepreneurship Club
Invention Competitions
Inventors Club
Making/Design/Do-It-Yourself (DIY)projects
Robotics Programs
Science Fair Projects
Scouting
4-H
Other

 

26. I have a strong desire to improve teaching and learning in either formal or informal environments and especially as it relates to the fields of STEM, innovation, or intellectual property:

27. My school principal or administrator/superintendent has endorsed my application to the USPTO National Summer Teacher Institute. Endorsement means my principal or administrator is aware of my application to this program and has agreed to support my efforts to take the lessons learned through participation in this Institute back to the classroom or to my school district. This also includes support by the administrator to allow the teacher to cooperate with any reasonable efforts in sharing learning experiences and outcomes with other teachers at the Institute and with the USPTO:

28. I understand that my principal or administrator may be contacted to verify awareness of my application to participate in this program:

29. I acknowledge that if I am selected to participate in this program the USPTO may contact my principal or school administrator to verify their endorsement:


 

 

Privacy Act Statement

The authority for the collection of this information is 5 U.S.C. § 301, 35 U.S.C. § 2, and E.O. 12862. The information you provide will be used to verify your identity and administer participation in the National Summer Teacher Institute. The information you provide is protected from disclosure to third parties in accordance with the Privacy Act. However, routine uses of this information may include disclosure to the following: Congressional offices; Federal, state, local or foreign agencies; a court, magistrate or administrative tribunal; law enforcement; agents or contractors; the Department of Justice; the National Archives and Records Administration; and agency customers in the course of distributing patent and trademark business information. Disclosure of the information by you is voluntary; however, failure to provide any part of the requested information may result in our inability to enroll you in the program. The applicable Privacy Act System of Records Notice for this information request is Commerce PAT/TM-19, Dissemination Events and Registrations, available at http://www.osec.doc.gov/opog/PrivacyAct/SORNs/pat-tm-19.html.