Broader Impacts Intake Form

Thank you for your interest in working with �鶹��Ѱ��Science Discovery. We are excited to support you in designing and implementing worthwhile, efficient, and rewarding broader impacts activities. We work with faculty and researchers in a variety of capacities. At one end of the spectrum, we can provide advice and connections to help you achieve your broader impacts goals, or alternately, our team of educational designers and instructors can take your expertise and turn it into broader impacts work that we deliver ourselves with very little first-hand involvement from you. We are also��happy to craft something that lies in between. Please complete the following requests for information to the best of your ability. If you’re still unsure of what you want to do for your broader impacts��work, or who the most appropriate audience might be, just leave those fields blank and we’ll work together to complete them. Our philosophy is that your��broader impacts work should integrate as seamlessly as possible into your research agenda, as well as��be a reflection of your lab’s interests and aptitudes.��Ideally, it should be something that feels rewarding enough for you to want to do, even outside of a grant’s timeframe. We look forward to working with you.��

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Your Name (First and Last):

Your Email Address:

List all PIs involved with your grant and their University and department affiliations:

Funding agency:

RFP title and link to call:

Internal deadline for grant:

External deadline for grant:

Fill in the bubble to indicate which of the following documents are needed by the internal versus external deadline:

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Other documents needed by internal or external deadline (please describe):

If you already have an idea for your Broader Impacts work, please describe the activities (including those to be carried out by someone other than �鶹��Ѱ��Science Discovery):

Description of target audience (elementary students, families, teachers, etc.):

Ideally, how much would you like to be involved in the implementation of your Broader Impacts work?

Other resources/personnel you might involve in Broader Impacts work (grad students, post-docs, a school teacher you might know, etc.):

Other Broader Impacts partners you plan to involve:

How did you hear about our offer of assistance with Broader Impacts efforts?

��鶹��Ѱ��Science Discovery electronic communication

��Broader Impacts Network (BIN) Website

��Office for Public & Community-Engaged Scholarship (formerly known as Office for Outreach & Engagement)

��Research and Innovation Office (RIO)

��Broader Impacts Expo

��Broader Impacts presentation given by Alexandra Rose

��鶹��Ѱ��Science Discovery staff

�� Other

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Broader Impacts Intake Form

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