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* 1. Name (Last, First)

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* 2. Email address:

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* 3. U.S. postal address:

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* 4. What is the full name of your institution or agency?

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* 5. Which of the following best describes your primary institution/agency? (choose one)

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* 6. Is your institution or agency a NEOSEC member?

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* 7. What is your main job/primary professional role? (choose one)

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* 8. Do you receive National Science Foundation (NSF) funding for scientific research (in addition to any funds you might receive from COSEE)?

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* 9. Have you previously engaged in broader impact programs?

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* 10. Please identify the type of partner(s) with whom you would consider collaborating (check all that apply):

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* 11. Please mark the appropriate box to indicate to what degree you agree with the following statement.

I am confident in my knowledge of the spectrum of broader impact programs that are available to me.

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* 12. Please mark the appropriate box to indicate to what degree you agree with the following statement.

Prior to engaging in broader impacts activities, I am able to evaluate factors such as inputs (e.g., time or other resources required), outputs (e.g., products to be created), and impacts (e.g., audiences reached).

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* 13. Please mark the appropriate box to indicate to what degree you agree with the following statement.

I am interested in collaborating with others on a project that promotes ocean science literacy.

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* 14. Please mark the appropriate box to indicate to what degree you agree with the following statement.

I have a good understanding of what it takes to make a successful collaboration.

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* 15. Do you have any special dietary needs?

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* 16. Are you planning to participate in the optional and guided tour of the Waquoit Bay National Estuarine Research Reserve after the workshop?

Thank you for completing the workshop registration for the Strategies for Engaging in Broader Impact Programs! The program coordinator for this workshop is Kim Frashure who can be reached via email at kfrashure@comcast.net. In late October additional workshop materials (travel directions and a final agenda) will be sent via email. We look forward to meeting you on November 4th at 9:00 a.m. at the Waquoit Bay National Estuarine Research Reserve (in the boathouse).

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