Research Infrastructure – Project and Participant Information

Faculty Research, Faculty Seed Research, Faculty Collaboration, STEM Education Research

*This form must be typed.

Section 1 – Faculty Profile

First Name: / Last Name:
Employment Status:
Award Type:
Award Amount:
Project Title:
Project Period:
Institution:
Official affiliate email address: / Phone:
Permanent Address:
City: / State: / Zip Code:
Gender: / ☐Male ☐Female / Ethnicity: / ☐Hispanic or Latino ☐Not Hispanic or Latino
Race: / ☐American Indian or Alaskan Native ☐Asian ☐Some Other Race
☐Native Hawaiian or other Pacific Islander ☐White
☐Black or African American
Disability? / ☐If yes, please elaborate:
Have you served in the United States Military Service? / ☐Yes ☐No

Section 2 – Participant Information

2.1 - Please check all CTSG Affiliate Institutions that participated in this project:
☐Central Connecticut StateUniversity ☐Eastern Connecticut State University
☐Fairfield University
☐Southern Connecticut State University
☐TrinityCollege
☐University of Bridgeport
☐University of Connecticut
☐University of Connecticut Health Center ☐University of Hartford
☐University of New Haven
☐Wesleyan University
☐Yale University / ☐Asnuntuck Community College
☐Capital Community College
☐Gateway Community College ☐Housatonic Community College
☐Manchester Community College
☐Middlesex Community College
☐Naugatuck Valley Community College
☐Northwestern CT Community College ☐Norwalk Community College
☐Quinebaug Valley Community College
☐Three Rivers Community College ☐Tunxis Community College
2.2.A - Please indicate any other partners or collaborators in this project. (Partners or collaborators include organizations which provided mentoring, facilities, presenters, staff, materials, or equipment at no cost.)
☐NASA Contractor ☐Non Profit
☐K-12 School
☐Other Industry Partnership/Collaboration
☐Department of Education ☐Community/Local / ☐Other NASA HQ Program Office ☐Other Federal Agency ☐Professional Society / ☐Museum/Planetarium ☐Higher Education Institution ☐State Government ☐None (no external collaborators)
2.2.B - Please list names of companies/organizations, please be specific:
2.2.C - Please explain their role, please be specific:
2.3 - Please complete for students who were “Direct Participants”. Each student listed here must complete their own Direct Participant form (available on our website).
Name / Gender / Enrolled / Email
☐Male
☐Female / ☐UG
☐Graduate
☐Male
☐Female / ☐UG
☐Graduate
☐Male
☐Female / ☐UG
☐Graduate
2.4 - Please list the number of participants for each category. (A participant is a person who benefited from or took part in project activities but did not receive direct funding “Indirect”). Each student noted in sections j, k, and l must complete their own Direct Participant form.
a. Teachers teaching grades k-4 / j. Community College students
b. Teachers teaching grades 5-8 / k. College undergraduate students
c. Teachers teaching grades 9-12 / l. College graduate students
d. Informal educators / m. Pre-service teachers
e. Community College faculty / n. Post-doctoral students
f. 4-Year college faculty / o. Administrators
g. Students in grades k-4 / p. Parents/Guardians
h. Students in grades 5-8 / q. Public At Large
i.Students in grades 9-12 / r. Other

Section 3 – Research Project Outcomes

Please indicate all of the following outcomes that have occurred (or are in progress) as a result of this project/research. (Please enter 0 or N/A when necessary.)
Outcome / Number / Further Information, such as title, conference name, date, links, etc.; please be specific.
Published works
Submitted manuscripts
Invited papers for presentation
Self-submitted papers for presentation at a conference
Outcome / Number / Further Information, such as where proposal was submitted; please be specific.
Patent applications
Patents granted
Patent licenses issued
Total of all technology transfer activities
Proposals submitted for additional funding from other sources
Total dollar amount requested via those proposals
Total number of proposals awarded from other sources
Total dollar amount awarded by these other successful proposals

Section 4 – Project Summary

1. Please provide a page detailing your project or research and/or how this grant has affected your career.In addition to the project summary, please include any available photographs detailing your grant work. These can be attached as pdf’s or jpeg’s to your email submission of this report form. The project summary and submitted photographs will be posted on our website and may be used in our newsletter.

NASA CT SPACE GRANT CONSORTIUM

203 Dana Hall, University of Hartford (Lead Institution), 200 Bloomfield Avenue, West Hartford, CT 06117

860.768.4813 ;