2011 NASA and Eco-Schools USA Climate Change Connections Pre-Institute Survey and Application

1. Page 1 of 4 - Getting to know you

Thank you for your interest in the Eco-Schools USA/NASA CCC program. To apply for this program we need more detailed information about you. This survey will help us to better understand your current skill and knowledge level and will also provide you with a bit more detail of the types of things we will be covering in this program. If you need additional information prior to filling out this survey, please be in touch with your regional contact person (found on the information flyer).

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* If chosen to participate in this program will you be able to obtain the written support of your administration?

Yes

I don't know

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* I understand that if selected for the NASA and Eco-Schools USA Climate Change Connections Institute that I am agreeing to, during the course of the 2011-2012 school year to:

- Be a partner in the ongoing development of the Eco-Schools USA Climate Change Connections curriculum.
- Participate in an on-line informational training titled, Climate Change 101.
- Engage in online or printed survey’s as asked by my regional contact.
- Participate in 2 phone conferences with your regional contact.
- Participate in two webinars as a part of a professional learning community.
- Implement Eco-Schools USA and appropriate modules of the Climate Change Connections curriculum.
- Provide a minimum of 5 photographs of student engagement. (no names will be necessary)
- Provide student examples of engagement found in the Evaluation Toolkit that will be provided at the Institute.

Yes

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* Some information about you

Your city:

Your e-mail address:

Best phone number to reach you:

Your school:

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* 1.Name:

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* 2a. Course # 1 of your probable course assignment for the 2010-2011 school year (best educated guess)

Course/Subject

Grade level

# sections

# students/section

Lab (Yes/No)

Years experience teaching this course

Average % class spent lecturing

Average % time students do hands-on work

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* 2b. Course # 2 of your probable course assignment for the 2010-2011 school year (best educated guess)

Course/Subject

Grade level

# sections

# students/section

Lab (Yes/No)

Years experience teaching this course

Average % class spent lecturing

Average % time students do hands-on work

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* 3a. Please describe the technology available in your classroom, including: # of computers, and access to: high speed internet, projection system, black-white printer, color printer, JAVA, and media flash player.

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* 3b. Please describe the technology available in the computer lab, including: # of computers, # days/week you have access to lab, how long you have access to lab, systems running current updates, JAVA, projection system, access to B/W and to color printers.

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* 4. Is your school classified as Title I, meaning that a certain percentage of the students at your campus qualify for the free or reduced lunch program?

Yes

Not Sure