2 survey

OMB#0925-XXXX Exp. Date: XX-XXXX

Burden Disclosure Statement: Public reporting burden for this collection of information is estimated to average 30 minutes per survey, 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 (0925-0486). Do not return the completed form to this address.

Please complete this voluntary survey. We welcome your feedback and appreciate your honesty.

1. General Questions

   1. What year did you complete the program?

   2. Please rate the following question: On a scale of 1-5 (1=no impact, 5=considerable impact), please indicate the impact this program has had on your professional career.

   3. Please provide the following demographic data:

      1. Name

      2. Company

      3. Address

      4. Address2

      5. City/town

      6. State

      7. Zip Code

      8. Country

      9. Email address

      10. Phone number

4. Please provide an alternative email

5. What professional degrees do you hold?

6. Are you currently performing clinical research, yes/no, other

7. What is your professional title?

8. What organization and/or department do you work for?

9. What is your primary field of concentration?

10. What is your academic status?

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11. What is your current appointment?

12. What are your funding sources:

    1. None

    2. K01 mentored Research Scientist Development

    3. K08 Mentored Clinical Scientist Development

    4. K12 Mentored Clinical Scientist Development

    5. K22 Career Transition Award

    6. K23 Mentored patient Oriented Research

    7. K24 Midcareer Investigator Award in patient Oriented Research

    8. K30 Clinical Research Curriculum Award

    9. R01 Research Project Grant Program

    10. R03 Small Group Program

    11. R21 Exploratory Developmental Research Grant Award

13. What is the dollar amount of your grant(s)?

    1. None

    2. Less than $50K

    3. $50K to $100K

    4. $100K to $250K

    5. $250K to $500K

    6. $500K to $1M

    7. Greater than $1M

14. Please list your publications

15. What could the Office of Clinical Research Training and Medical Education Improve on regarding the content of the program?

16. What are the most important clinical research challenges facing you in your career this year?

17. Please provide any additional comments.

18. List your ABMS certifications.

19. List your current licensure

20. What proportion of your time is devoted to the following:

    1. Direction patient care: _____%

    2. Research: _____%

    3. Teaching: _____%

    4. Administration: _____%

21. Please tell us how your NIH training has contributed to your current clinical competence in the following areas on a scale of 1-5, 1= not at all, 5= considerable impact?

    1. Medical Knowledge

    2. Patient Care

    3. Interpersonal & Communication Skills

    4. Professionalism & Ethics

    5. Practice-based Learning and Improvement

    6. Systems-based Practice