Minnesota K-12 Academic Science Standards Committee Application (2018-2019) Survey

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* 1. I have read the Assumptions for Guiding the Standards Committee's Work - Science, and agree to abide by these guidelines if I am selected for the Standards Committee.

Yes

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* 2. Contact Information

First Name:

Last Name:

Address

City

State

Zip

Email Address

Work Phone Number

Mobile or Home Phone Number

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* 3. Please provide information about your employer:

School, institution or organization name:

School district name (if applicable):

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* 4. At the time of this application, the level of funding for the standards committee is uncertain. If the funding is at a low level, would you or your employer be willing to provide time away from work, substitute teacher funding, and travel expenses? Please identify what costs are able to be covered.

Substitute costs

Mileage to committee meetings

Hotel costs (if necessary)

Food and other costs

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* 5. Indicate the size and type of your local school district from the choices given below:

Minneapolis/St. Paul

Other 7-county metro area

Outstate more than 2,000 students

Outstate 1,000-1,999 students

Outstate 500-999 students

Outstate less than 500 students

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* 6. Please identify your ethnicity (optional). (Check ALL that apply.)

American Indian/Alaska Native

Asian

Black/African American

Hispanic/Latino

Native Hawaiian/Pacific Islander

White

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* 7. Which of the following groups do you consider yourself a member of? (Check ALL that apply.)

Parent of school-age child(ren)

Currently serving school board or charter school board member

Licensed K-12 educator (please identify your grade level below)

Teacher on Special Assignment, Curriculum coordinator

Licensed elementary school principal currently administering an elementary school site

Licensed secondary school principal currently administering a middle school or junior high school site

Licensed secondary school principal currently administering a senior high school site

Retired, currently licensed K-12 educator (please identify your grade level below)

Retired, currently licensed elementary principal

Retired, currently licensed secondary principal

Postsecondary educator

Retired, postsecondary educator

Superintendent

Science organization representative

Science Informal Educator

Business representative

Other (please specify)

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* 8. If you represent a science organization, please provide the name in the box below.

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* 9. If you represent a state agency, please provide the name in the box below.

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* 10. If you represent a business, please provide the name in the box below.

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* 11. If you represent a non-profit organization, please provide the name in the box below.

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* 12. Science Educators, please indicate your primary science teaching area(s) below. (Check ALL that apply.)

	Grades K-2	Grades 3-6	Grades 6-8	Grades 9-12	Postsecondary
General Science	General Science Grades K-2	General Science Grades 3-6	General Science Grades 6-8	General Science Grades 9-12	General Science Postsecondary
Earth Science	Earth Science Grades K-2	Earth Science Grades 3-6	Earth Science Grades 6-8	Earth Science Grades 9-12	Earth Science Postsecondary
Life Science	Life Science Grades K-2	Life Science Grades 3-6	Life Science Grades 6-8	Life Science Grades 9-12	Life Science Postsecondary
Physical Science	Physical Science Grades K-2	Physical Science Grades 3-6	Physical Science Grades 6-8	Physical Science Grades 9-12	Physical Science Postsecondary
Chemistry	Chemistry Grades K-2	Chemistry Grades 3-6	Chemistry Grades 6-8	Chemistry Grades 9-12	Chemistry Postsecondary
Physics	Physics Grades K-2	Physics Grades 3-6	Physics Grades 6-8	Physics Grades 9-12	Physics Postsecondary
Engineering	Engineering Grades K-2	Engineering Grades 3-6	Engineering Grades 6-8	Engineering Grades 9-12	Engineering Postsecondary
None of the above	None of the above Grades K-2	None of the above Grades 3-6	None of the above Grades 6-8	None of the above Grades 9-12	None of the above Postsecondary

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* 13. Science Educators, please indicate all of the other science areas in which you have teaching experience. (Check ALL that apply.)

	Grades K-2	Grades 3-6	Grades 6-8	Grades 9-12	Postsecondary
General	General Grades K-2	General Grades 3-6	General Grades 6-8	General Grades 9-12	General Postsecondary
Earth Science	Earth Science Grades K-2	Earth Science Grades 3-6	Earth Science Grades 6-8	Earth Science Grades 9-12	Earth Science Postsecondary
Life Science	Life Science Grades K-2	Life Science Grades 3-6	Life Science Grades 6-8	Life Science Grades 9-12	Life Science Postsecondary
Physical Science	Physical Science Grades K-2	Physical Science Grades 3-6	Physical Science Grades 6-8	Physical Science Grades 9-12	Physical Science Postsecondary
Chemistry	Chemistry Grades K-2	Chemistry Grades 3-6	Chemistry Grades 6-8	Chemistry Grades 9-12	Chemistry Postsecondary
Physics	Physics Grades K-2	Physics Grades 3-6	Physics Grades 6-8	Physics Grades 9-12	Physics Postsecondary
Engineering	Engineering Grades K-2	Engineering Grades 3-6	Engineering Grades 6-8	Engineering Grades 9-12	Engineering Postsecondary
None of the above	None of the above Grades K-2	None of the above Grades 3-6	None of the above Grades 6-8	None of the above Grades 9-12	None of the above Postsecondary

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* 14. Science Educators: Please specify the course(s) that you teach:

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* 15. If you are an Educator not in science education, please indicate the subject area(s) and grade level(s) you teach:

Subject area(s):

Grade level(s):

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* 16. If you have substantive experience/expertise teaching Advanced Placement (AP), International Baccalaureate (IB) or concurrent enrollment courses, please describe your experience/expertise including courses taught and grade levels (please describe in 100 words or less; full sentences are not necessary).

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* 17. If you have substantive experience/expertise with Special Education students, please list your license name and describe your experience/expertise (please describe in 100 words or less; full sentences are not necessary).

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* 18. If you have substantive experience/expertise with English Learners (EL)/English as a Second Language (ESL) students, please describe your experience/expertise (please describe in 100 words or less; full sentences are not necessary).

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* 19. If you have substantive experience/expertise with Students of Poverty, please describe your experience/expertise (please describe in 100 words or less; full sentences are not necessary).

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* 20. If you have substantive experience/expertise with Minnesota American Indian tribes and communities, describe your experience/expertise (please describe in 100 words or less; full sentences are not necessary).

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* 21. Are you enrolled in one of the eleven Minnesota Tribal Nations or are you a descendent of a Tribal Member?

Yes

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* 22. If you have substantive experience/expertise with culturally relevant curriculum and teaching practices, describe your experience/expertise (please describe in 100 words or less; full sentences are not necessary).

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* 23. If you have substantive experience/expertise with Technology and Information Literacy or Computer Science, describe your experience/expertise (please describe in 100 words or less; full sentences are not necessary).

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* 24. Summarize your interest and qualifications for serving on this committee. Include formal training/degrees in the subject area(s), work or volunteer experience, and any other information you feel is relevant (please describe in 100 words or less; full sentences are not necessary).