Form 1 Funding Source Questionnaire

OMB #: 0925-xxxx

Expiration Date: xx/xxxx

Attachment 1: Funding Source Questionnaire

In [YEAR OF ARTICLE PUBLISHED] you published an article titled: [TITLE OF ARTICLE] in [NAME OF JOURNAL].

We would like information on the funding source(s) for the research that served as the basis for your published article. This information was not included in your publication.

The following questions will require 5 minutes to complete.

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx). Do not return the completed form to this address.

1. Was your published article based on a study that received any funding?

 Yes  No [If NO, TERMINATE]  You have completed the questionnaire. We thank you for your time. If you have questions about this study or your participation, please contact Dr. Amanda Greene by email at amanda.greene@nih.gov or by phone at (301) 496-9601.

2. Name of Funding Agency

If your published article was based on more than a single funded study, name all agencies that funded those studies.

1. Funding Agency 1

 Don’t Know/Don’t Remember

2. Funding Agency 2

 Don’t Know/Don’t Remember

3. Funding Agency 3

 Don’t Know/Don’t Remember

3. Type of Funding Source

For each funding agency listed in Question 2, please select the type of funding source.

1. Funding Source 1 [drop down box]

 U.S. Government Funding

 Academic Institution

 Private Foundation

 Commercial Entity

 Professional Organization

 State/local Government

 Other National Government

 Other [please specify]

 Don’t Know/don’t remember

2. Funding Source 2 [refer to drop down box response options above]

3. Funding Source 3 [refer to drop down box response options above]

The following questions are about the studies that were funded by each funding agency that you listed previously.

4. Name of Funded Study

Please name all studies funded by:

1. Funded Study Name 1

 Don’t Know/Don’t Remember

2. Funded Study Name 2

 Don’t Know/Don’t Remember

3. Funded Study Name 3

 Don’t Know/Don’t Remember

5. Start Year of Funded Study

Select start year for each study listed in Question 4.

1. Start Year of Funded Study 1 [drop down box]

 Before 1997

 1998

 1999

 2000

 2001

 2002

 2003

 2004

 2005

 2006

 2007

 2008

 2009

 2010

 Don’t Know/Don’t Remember

2. Start Year of Funded Study 2 [refer to drop down box response options above]

3. Start Year of Funded Study 3 [refer to drop down box response options above]

6. Duration of Funded Study

Approximate length of each study listed in Question 4.

1. Duration of Funded Study 1 [drop down box]

 1 year or less

 2 years

 3 years

 4 years

 More than 5 years

 Don’t Know/Don’t Remember

2. Duration of Funded Study 2 [refer to drop down box response options above]

3. Duration of Funded Study 3 [refer to drop down box response options above]

7. Please enter any additional comments, information, or questions you would like to share with NINR:

You have completed the questionnaire. We thank you for your time. If you have questions about this study or your participation, please contact Dr. S. Lisbeth Jarama by email at jaramasl@mail.nih.gov or by phone at (301) 986-1891.

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