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2006

Pre-college Education Program

####### Teaming Teachers with INL

**Return Completed Application by March 1, 2006 to:**

**Brenda Greenhalgh**

**Pre-college Education Programs**

**2525 Fremont Avenue**

## Idaho Falls ID 83415-3760

**Telephone (208) 526-9399 Fax (208) 526-2089**

**E-mail: <Brenda.Greenhalgh@inl.gov>**

![](media/image2.wmf){width="0.9166666666666666in"
height="0.9166666666666666in"}The INL is a facility operated for the
U.S. Department of Energy

**TEAMING TEACHERS WITH INL**

### 

### Teachers have a professional development opportunity to team with scientific and technical experts at the Idaho National Laboratory (INL). During an eight-week summer program, teachers participate in a discipline-compatible research or application project. Teachers are exposed to the real world of science and given opportunities to apply concepts in science, mathematics, and technology that are linked to courses taught in typical teacher education curricula. Teachers have confidence-building opportunities that deepen their knowledge and strengthen their curriculum development and teaching skills in science, mathematics, and technology.

### **INTRODUCTION**

### The Teaming Teachers with INL program is open to current classroom teachers or teachers who have been hired for the next academic year at the time the appointment starts. 

### Teachers that demonstrate an intellectual curiosity and enthusiasm for learning, dedication to teaching, and self-motivation for improvement are considered for the program. All teacher participants must be U. S. citizens or permanent resident aliens.

### 

### Selection for one of the programs is based on completion of the application process, including a statement of interest, and results of an interview. As a result of the summer experience, participants develop valuable collegial relations and leadership skills. They energize students to think about careers in science, mathematics, engineering, or technology. Through their own excitement, they help to revitalize the teaching profession. Through their contributions to the research projects, participating teachers help the INL build academic excellence in science and technology. 

**PROGRAM DATES** Start Date June 12, 2006

> End Date August 4, 2006

#### STIPENDS

#### The following matrix shows that stipends for teachers are based on academic credentials and capped at the third year of participation.

####  [1^st^ Time]{.underline} [2^nd^ Time]{.underline} [3^rd^ Time]{.underline}

#### Teacher with Bachelors Degree \$4000 (500/wk) \$4400 (550/wk) \$4800 (600/wk)

Teacher with Masters Degree \$5200 (650/wk) \$5400 (675/wk) \$5600
(700/wk)

Teacher with Doctoral Degree \$6000 (750/wk) \$6200 (775/wk) \$6400
(800/wk)

All stipends will be issued at the end of each month.

**COURSE CREDIT**

Teachers may earn in-service credit for re-certification and/or salary
advancement, or undergraduate or graduate credit through Idaho State
University that can be applied toward a degree. All teacher participants
will focus on conducting their projects, maintaining a reflective
journal, periodically meeting with other teachers to establish a sense
of community and strengthen professional development, and producing an
outline of a potential publication or presentation.

#### HOUSING ALLOWANCE

Out-of-state participants receive to/from travel and a \$500/month
housing allowance.

**APPLICATION PROCESS FOR TEACHERS**

1.  Complete Section 2 of the application form. Please type or print.

2\. Attach a copy of your resume.

3\. Acquire and attach one letter of recommendation or endorsement on
school letterhead from an authorized school or school district official.

4.  Complete Section 3 of the application form. Please type or print.

5.  Complete and sign the attached medical form.

6.  Sign the attached Affirmative Action Questionnaire.

7.  Sign the attached Privacy Waiver and Release.

8.  Return the completed application form and attachments to Brenda
    Greenhalgh by March 1, 2006.

**TEACHER APPLICATION FORM**

## PERSONAL INFORMATION

Name: SS#

###  Last First Middle

Home Address:

[( )]{.underline}

> Home Phone

City State Zip E-mail Address

Birthplace Birthdate

Fellowships can be awarded only to U.S. citizens or to persons with
permanent resident status. Check one.

Citizenship USA PRA (Please attach a copy of the permanent resident
status registration card.)

**EDUCATION INFORMATION**

Name and address of school where presently teaching.

School Name Principal's Name

School Address

City State Zip School Phone

Years teaching experience

School Fax

**PROFESSIONAL EXPERIENCE**

Teaching assignments this school year.

> Course Title Grade Level Periods per Day

Anticipated teaching assignments next year.

> Course Title Grade Level Periods per Day

**SECTION 3: TEACHER STATEMENT OF INTEREST**

Write a brief statement of interest. Explain the type of research or
application project that interests you (e.g., biology, chemistry,
mathematics, environmental science, physics, technology or computer
applications). Include any intended professional development activities
such as publication or presentation as a follow-through to the summer
research program.

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Explain any work-related experiences and training that you feel would
help the committee place you.

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Have you had previous research experience at a research laboratory or
the INL? Yes No

If yes, identify the facility, location, and research program.

Describe your personal and educational philosophy.

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**CONFIDENTIAL MEDICAL INFORMATION AND EMERGENCY NOTIFICATION**

Each fellowship participant must be covered by medical or hospital
insurance prior to his or her arrival on site at the INL. Teachers will
not be able to participate in Teaming Teachers with INL or on Student
Action Teams if this requirement is not met.

Name Birthdate [\_\_]{.underline} Gender: M F[\_\_]{.underline}

Street Address

City State Zip Code

Home Telephone Social Security \#

Date of Last Tetanus Shot

Drug Allergies

Physician Physician's Telephone

Medical Conditions or Previous Surgery

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

Regular Medications

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

Special Dietary Requirements (include food allergies)

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

Special Physical Needs

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Emergency Contact Telephone

Medical/Hospital

Insurance Carrier Policy \#

Signature Date

**AFFIRMATIVE ACTION QUESTIONNAIRE**

Your signature is required. The completion of this form is optional. If
you decline to provide the information, your decision will not affect
the consideration of your application.

The Idaho National Laboratory (INL) is an administrator of science
education programs sponsored directly or indirectly by federal funds. It
has a continuing commitment to monitor the operation of its review and
award processes to identify and address any inequities based on gender,
race, ethnicity, or handicap of fellowship awardees. To help us gather
the information needed for this process, please complete and return a
single copy of this form with the application.

The information from this form will be retained by Pre-college Education
and used for statistical purposes only. This is confidential information
accessible only to Pre-college Education personnel and our sponsors. It
will be treated as confidential to the extent permitted by law.

**INSTRUCTIONS**

Place an "X" in the appropriate areas. If two or more ethnic categories
are applicable, choose the one category with which you most clearly
identify.

Race and/or Ethnic Origin (check one)

( ) Caucasian not of Hispanic origin (Having origins in any one of the
original peoples of Europe, North Africa, or the Middle East)

( ) African-American (Having origins in any of the Black racial groups
of Africa)

( ) Hispanic (Of Mexican, Puerto Rican, Cuban, Central/South American or
other Spanish culture of origin, regardless of race)

( ) American Indian (Having origins in any of the original peoples of
North America, and maintaining cultural identification through tribal
affiliation or community recognition)

( ) Asian or Pacific Islander (Having origins in any of the original
peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the
Pacific Islands -- for example, India, China, Japan, Korea, Philippine
Islands, and Samoa)

( ) Other

Gender

( ) Female ( ) Male Birthdate

Month Day Year

Physical/mental handicap (physical or mental impairment that
substantially limits one or more major life activities such as
blindness, deafness, or mobility impairment): Yes No

Print Name Signature Date

**PRIVACY WAIVER AND RELEASE**

A number of informational documents will be generated as a result of
your application. Among those documents may be application forms,
letters of recommendation, education certification, transcripts of
grades, facility endorsement, reports of graduate record examinations,
security questionnaires, etc. The Department of Energy Organization Act
(P.L. 95-91) and the Atomic Energy Act of 1954 as amended (P.L. 83-703)
authorize the information requested.

The application and related documents are reviewed by the INL. The
reviews are made to determine whether the applicant meets the selection
criteria established for participation in the program. Security
questionnaires and related documents are needed when security access
authorizations are required by the INL.

Since the informational documents are essential to ensure a fair
selection process, an applicant cannot be considered unless he or she
provides the appropriate information.

**RELEASE OF PERSONAL INFORMATION**

In accordance with the Privacy Act of 1974 (Public Law 93-579), the
Family Educational Rights and Privacy Act (Public Law 93-380), the
Energy Reorganization Act of 1974 (Public Law 93-438) and the Atomic
Energy Act of 1954 as amended, Chapter 12, Control of Information,
Section 145b, any of the following items or related attachments of
personal information that are supplied by me may be released to the U.S.
Department of Energy (DOE) or other Federal agencies, participating
Federal, industrial, and educational entities, and cognizant review
panels as needed by the INL Academic Center for Excellence, Inc. to
facilitate its purposes as an administrator of education programs.

a.  Application form and related attachments

b.  Transcripts of grades

c.  Letter of recommendation

d.  Resume

Print Name Signature

Date

*Note: This "Release of Personal Information" must be signed and
returned with your application for consideration before an award can be
made.*

**USE OF OTHER PARTICIPANT INFORMATION**

To promote, evaluate, or otherwise describe this award, I give
permission to the INL, DOE and their agents to use any program-related
photographs in which I appear and to use and cite any evaluative or
judgmental comments, oral or written, attributable to me which I may
make about the program.

Signature Date

*Note: Consideration for an award is not contingent upon your consent to
this "Use of Other Participant Information."*