Precollege Program Form

Sponsoring Institution Name:

Project Information

Name of Project:

Contact Person:

Address:

City:

State:

Zip Code: Contact Phone:

Name of sponsor(s) if other than affiliate: (limited to 1,900 characters – approx. 30 lines)

Location of Project Activities:

NASA Center(s)

University Campus(es)

Elementary / Middle / High School

Community Facilities

Museum / Planetarium(s)

Industry or Private sector Facilities

Other

Project Status:

End date of Project: th day of , 20

Descriptive Information

Please provide a brief description of the project: (limited to 1,900 characters – approx. 30 lines)

[If needed, more description can go here…]: (limited to 1,900 characters – approx. 30 lines)

Are Evaluation mechanisms in place?

Describe Evaluation Methodology: (limited to 1,900 characters – approx. 30 lines)


Primary Discipline:

(Choose most closely related discipline)

Aeronautical/Aerospace Computer Science Mathematics

Agricultural Earth Sciences Mechanical

Anthropology Economics Medicine/Medical Research

Architectural Education Mining

Architecture Electrical/Electronic Petroleum & Natural Gas

Art Engineering Molecular/Cell Biology

Astronomy Engineering Mechanics Nuclear

Astrophysics Engineering Science Oceanography

Atmospheric Science Environmental Philosophy

Biochemistry Environmental Science Physical Sciences

Bioengineering Geography Physics

Biology Geology Planetary Geo Sciences

Botany Geophysics Planetary Sciences

Chemical Health Science/Nutrition Political Science/Pub. Policy

Chemistry History Psychology

Civil Industrial Social Sciences

Climatology/Meteorology Life Sciences Sociology

Computer Materials Sci./Engineering Zoology

Other… (Indicate above)

Also use this field to enter actual

discipline name and/or short description

of discipline.

If Other, enter name of Discipline:

Choose most closely related discipline

If applicable, Secondary Discipline:

Also use this field to enter actual

discipline name and/or short description

of discipline.

If Other, enter name of Discipline:

Funding and Collaboration Information

Actual Sources of Funding for this reporting period (include cash or non cash).

Enter whole number only: / CASH
NASA Space Grant: / 0
Other Federal: / 0
Carryover: / 0 / NON-CASH
Industry: / 0 / 0
Lead Institution: / 0 / 0
Non-Profit Organizations: / 0 / 0
Academic Affiliates: / 0 / 0
State/Local Government: / 0 / 0
Participants: / 0 / 0
Other: / 0 / 0
Totals: / 0 / 0
Actual Cost of Project for this reporting period (or contribution if supplement):
Enter whole number only: / 0
Balance/Difference: / 0

Please provide reason if no project costs and/or funding sources listed:

(limited to 1,900 characters – approx. 30 lines)

Collaborative efforts (mark all that apply):

In Same Department

Other Departments in same Institution

Other Institution of Higher Education

Community College

K-12 Institution(s)

Education Resource Centers

Non-Profit Organizations

Underrepresented Organizations

Industry

Community Partnership

Give name of business and type of industry and describe collaboration:

(limited to 1,900 characters – approx. 30 lines)

NASA Installation(s) (mark all that apply)

Ames Research Center

Dryden Flight Research Center

Goddard Space Flight Center

Jet Propulsion Laboratory

Johnson Space Center

Kennedy Space Center

Langley Research Center

Glenn Research Center at Lewis Field

Marshall Space Flight Center

Stennis Space Center

Wallops

NASA Headquarters

NASA Installation Collaboration – Please specify:

(limited to 1,900 characters – approx. 30 lines)

NASA Enterprises (mark all that apply)

Human Exploration and Development of Space

Earth Science

Office of Aerospace Technology

Space Science

List type of Collaboration:

(limited to 1,900 characters – approx. 30 lines)

Other Space Grant Programs – Please Specify (List Consortium and name of program)

(limited to 1,900 characters – approx. 30 lines)

Other Federal Government – Please Specify (List Agency Name):

(limited to 1,900 characters – approx. 30 lines)

Other State Agencies – Please Specify:

(limited to 1,900 characters – approx. 30 lines)

Other Collaboration(s) – Please Specify:

(limited to 1,900 characters – approx. 30 lines)

Additional Collaboration Information – Please Specify:

(limited to 1,900 characters – approx. 30 lines)

Scheduling

Mark all that apply:

School Year

Summer

During School

After School

Weekend

Activity and Participant Information

Activities (mark all that apply)

Conference

Science Fair/Exhibit

Workshop

Academic Program

Other

The project was designed to promote:

Students (choose one):

Teachers (choose one):

Components (mark all that apply):

Book

Course Outline

Course Revision

Demonstration

Field Trip

Hands-on

Lab Tour

Lab

Lesson Plan

Mentors

Other Components

Problem Sets

Research

Role models for underrepresented groups

Software

Teacher’s Manual

Video

Wall Sheets

Number of Teachers.

Enter Number only:

Male / Male / Female / Female / Unknown
Not Underrep / Underrep / Not underrep / Underrep / Race/Gender
Or disabled / Or disabled
Grades K-4
Grades 5-8
Grades 9-12

Number of Students.

Enter Number only:

Male / Male / Female / Female / Unknown
Not Underrep / Underrep / Not underrep / Underrep / Race/Gender
Or disabled / Or disabled
Grades K-4
Grades 5-8
Grades 9-12

Number of Parents:

Number of Administrators:

Are any kind of recruitment and/or retention strategies for members of underrepresented groups in place? If so, please describe:

(limited to 1,900 characters – approx. 30 lines)

Did the project target underrepresented minority groups and/or persons with disabilities?

If so, mark the group(s) targeted:

African American Hispanic

Pacific Islander Native American

Persons with Disabilities

With respect to underrepresented groups, note the level of project participation as Below, As, or Exceeding the population represented in your state:

African American:

Hispanic:

Pacific-Islander:

Native American:

Persons with Disabilities:

Was support provided for any of the following standards? (mark all that apply):

National Mathematics Standards

National Science Standards

National Geography Standards

National Technology Standards

State Frameworks

Local Frameworks

Other

Overall Comments: (limited to 1,900 characters – approx. 30 lines)