SurveyMonkey Powered Online Survey

Welcome to the Physicists To-Go program! This year you will be matched with a physicist according to your topic priority. You can select up to 3 different topics and we hope to match you with your prioritized topic first. To better ensure receiving a match, make sure you fill out all fields on the form. If you teach multiple sections of the same course and want the same presentation delivered, you only need to fill out form once and indicate the number of classes. If you teach multiple courses and need different presentations, then please fill the form out multiple times.

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* 1. Honorific:

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* 2. Name/ Address:

Name *

School Name *

Address *

City/Town *

State/Province

ZIP/Postal Code *

Country *

Email Address *

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* 3. School level:

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* 4. Your school’s timezone:

Please select your preferred topic and time.
Note, the format of the virtual visit will be determined by you and the physicist once you are paired, and may include a short presentation, Q & A with the class, a demo, or interactive activity led by the physicist. We understand that you may teach different courses. If you teach the same course multiple times and are requesting the same topic, there is space to indicate this below. If you teach multiple courses, then please fill the survey out for each individual course type.

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* 5. You can select up to 3 different topics based on your priorities. You will get matched for only one of your topics.

	Topic	Month
Priority #1:	Priority #1: Topic menu	Priority #1: Month menu
Priority #2:	Priority #2: Topic menu	Priority #2: Month menu
Priority #3:	Priority #3: Topic menu	Priority #3: Month menu

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* 6. What is the level of the physics/science class the physicist will join?

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* 7. For this topic and date, how many classes (of the same type e.g 2 IB Physics classes) would you like to schedule this visit for? (if you have another course you would like to request a visit for, please fill out survey again)

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* 8. To the best of your knowledge, what percentage of your students belong to the following race/ethnicity group?

	None	1-10%	11-20%	21-40%	41-60%	61-80%	81-90%	>91%	Unsure
Hispanic, Latnix, Spanish origin	Hispanic, Latnix, Spanish origin None	Hispanic, Latnix, Spanish origin 1-10%	Hispanic, Latnix, Spanish origin 11-20%	Hispanic, Latnix, Spanish origin 21-40%	Hispanic, Latnix, Spanish origin 41-60%	Hispanic, Latnix, Spanish origin 61-80%	Hispanic, Latnix, Spanish origin 81-90%	Hispanic, Latnix, Spanish origin >91%	Hispanic, Latnix, Spanish origin Unsure
Black or African American	Black or African American None	Black or African American 1-10%	Black or African American 11-20%	Black or African American 21-40%	Black or African American 41-60%	Black or African American 61-80%	Black or African American 81-90%	Black or African American >91%	Black or African American Unsure
Asian (South Asian, South East Asian, East Asian, Pacific Islander/Native Hawaiian)	Asian (South Asian, South East Asian, East Asian, Pacific Islander/Native Hawaiian) None	Asian (South Asian, South East Asian, East Asian, Pacific Islander/Native Hawaiian) 1-10%	Asian (South Asian, South East Asian, East Asian, Pacific Islander/Native Hawaiian) 11-20%	Asian (South Asian, South East Asian, East Asian, Pacific Islander/Native Hawaiian) 21-40%	Asian (South Asian, South East Asian, East Asian, Pacific Islander/Native Hawaiian) 41-60%	Asian (South Asian, South East Asian, East Asian, Pacific Islander/Native Hawaiian) 61-80%	Asian (South Asian, South East Asian, East Asian, Pacific Islander/Native Hawaiian) 81-90%	Asian (South Asian, South East Asian, East Asian, Pacific Islander/Native Hawaiian) >91%	Asian (South Asian, South East Asian, East Asian, Pacific Islander/Native Hawaiian) Unsure
Native American	Native American None	Native American 1-10%	Native American 11-20%	Native American 21-40%	Native American 41-60%	Native American 61-80%	Native American 81-90%	Native American >91%	Native American Unsure
Other underrepresented group	Other underrepresented group None	Other underrepresented group 1-10%	Other underrepresented group 11-20%	Other underrepresented group 21-40%	Other underrepresented group 41-60%	Other underrepresented group 61-80%	Other underrepresented group 81-90%	Other underrepresented group >91%	Other underrepresented group Unsure

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* 9. To the best of your knowledge, what percentage of your students are eligible for free and reduced lunch?

None

1-10%

11-20%

21-40%

41-60%

61-80%

81-90%

>91%

Unsure

None

1-10%

11-20%

21-40%

41-60%

61-80%

81-90%

>91%

Unsure

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* 1. Honorific:

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* 2. Name/ Address:

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* 3. School level:

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* 4. Your school’s timezone:

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* 5. You can select up to 3 different topics based on your priorities. You will get matched for only one of your topics.

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* 6. What is the level of the physics/science class the physicist will join?

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* 7. For this topic and date, how many classes (of the same type e.g 2 IB Physics classes) would you like to schedule this visit for? (if you have another course you would like to request a visit for, please fill out survey again)

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* 8. To the best of your knowledge, what percentage of your students belong to the following race/ethnicity group?

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* 9. To the best of your knowledge, what percentage of your students are eligible for free and reduced lunch?

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* 10. Additional Comments: