R&D Spring 2016 Pilot Application

General Information & Demographics

Question Title

* 1. Please complete the information below:

Name: *

School/Organization: *

Address:

Address 2:

City/Town:

State:

ZIP:

Email Address: *

Phone Number: *

Question Title

* 2. Which of the following best describes your position? (Check all that apply)

Teacher

Administrator

Superintendent

Curriculum Specialist

Program Coordinator

Parent

Volunteer

Out-of-School Time Educator

Other (please specify)

Question Title

* 3. Which of the following applies to the students being served through your school/organization? (Check all that apply.)

Early Childhood/Primary Center

Elementary (K-2)

Elementary (3-5)

Middle School (6-8)

High School (9-12)

Out-of-School Time/Afterschool*

Other*

*Please specify age group(s) served:

Question Title

* 4. What is the percentage of students based on gender?

Female

Male

Question Title

* 5. What is the percentage of students based on ethnicity?

African American/Black

American Indian/Alaskan Native

Asian/Pacific Islander

Hispanic

White/Caucasian

Other

Question Title

* 6. What is the percentage of students on free/reduced lunch?

Question Title

* 7. Check all that apply for the following priority categories: (*able to provide supporting documentation upon request)

Low SES School*

Race to the Top "Turnaround School"*

Rural and/or Rural Low Income School*

Urban School

Current ASSET Member

Question Title

* 8. Is your school/organization willing to participate in a focus group to reflect upon your experience in a pilot?

Yes

Question Title

* 9. Is your school/organization willing to provide evidence of student and/or teacher outcomes in the form of interviews, surveys, student work samples, video, photography, and/or site observations?

Yes

Question Title

* 1. Please complete the information below:

Question Title

* 2. Which of the following best describes your position? (Check all that apply)

Question Title

* 3. Which of the following applies to the students being served through your school/organization? (Check all that apply.)

Question Title

* 4. What is the percentage of students based on gender?

Question Title

* 5. What is the percentage of students based on ethnicity?

Question Title

* 6. What is the percentage of students on free/reduced lunch?

Question Title

* 7. Check all that apply for the following priority categories: (*able to provide supporting documentation upon request)

Question Title

* 8. Is your school/organization willing to participate in a focus group to reflect upon your experience in a pilot?

Question Title

* 9. Is your school/organization willing to provide evidence of student and/or teacher outcomes in the form of interviews, surveys, student work samples, video, photography, and/or site observations?

Question Title

* 10. Why is your school/organization interested in participating in an ASSET STEM Education pilot?