NIEHS Data Collection Form

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Overview

Instructions
2. Personal Information
3. Contact Information
4. Pre-Training Information
5. In Training Experience
6. Career Highlights
7. Employment
8. Fellowships
9. Honors Awards
10. New Competitive Funding
11. Post-Training Education
12. Posters
13. Product or Policy Dev
14. Publications
15. Students

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Sheet 1: Instructions

Directions for Trainees			OMB NO.: 0925-0568			Exp. Date: 06/30/2019
Please take 10-15 minutes to review this spreadsheet and update or provide any new information that will help us demonstrate
the value of the T32 training program.
If you only have a limited amount of time to provide new information, we ask that you focus on providing information about any employment you have
had since leaving the training program (see Tab7 Employment Tab) and on any career highlights (Tabs 6-15)
that you would like to report (See Tab 6, Career Higlights).
Making Changes to Data Imported from IMPAC II (Fields shaded gray )
If a field is shaded gray, that information is imported from the NIH IMPAC II system, via either the Commons profile or the xTrain module. If you
need to make changes to information in a gray field, you must do so in IMPAC II not CareerTrac.
See the eRA Commons user guide for step by step instructions to enter or edit your personal profile information. The link is listed below
http://era.nih.gov/files/personal_profile_userguide.pdf
Returning the Spreadsheet
Please return the form to the Principal Investigator for the [University] T32 program by 03/24/2018.
PI email address:	[pi@email.com]
Respondent Burden Statement
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, 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 0925-0568
Do not return the completed form to this address.
This questionnaire includes the following sections:
Personal Information------------------------------------------Tab 2
	This section contains questions regarding your personal information, including name and email address.
Contact Information-------------------------------------------Tab 3
	This section contains questions regarding your mailing address and phone number.
Pre-Training Information-------------------------------------Tab 4
	This section contains questions regarding your professional and educational history before your T32 funding / training
In-Training Experience -----------------------------------------Tab 5
	This section contains questions regarding your T32-funded training experience. It also contains questions regarding the degree or certificate earned through your T32-funded training, the start and end date of your funding period, and mentor data etc…
Accomplishments-----------------------------------------------Tab 6 - 15
	This section contains questions regarding your personal achievements that can be attributed to your T32-funded training.
	> Career Highlights------------------------------------------------------Tab 6
	> Employment------------------------------------------------------------Tab 7
	> Fellowship---------------------------------------------------------------Tab 8
	> Honor and Awards----------------------------------------------------Tab 9
	> New Competitive Funding------------------------------------------Tab 10
	> Post-Training Education---------------------------------------------Tab 11
	> Posters at Scientific Meeting---------------------------------------Tab 12
	> Product or Policy Development-----------------------------------Tab 13
	> Publications-------------------------------------------------------------Tab 14
	> Students------------------------------------------------------------------Tab 15

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Sheet 2: 2. Personal Information

Personal Information
First Name:
Middle Name:
Last Name :
Suffix (ie. Jr., Sr., I.,):
Address Line 1:
Address Line 2:
Address Line 3:
Address Line 4:
Address Line 5:
City:
State:
Country:
Postal Code:
Phone Number:
Fax Number:
Email Address:
Training Status:

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Sheet 3: 3. Contact Information

Alternative Contact Information
Alternative Address Line 1:
Alternative Address Line 2:
Alternative Address Line 3:
Alternative Contact City:
Alternative Contact State:
Alternative Contact Country:
Alternative Contact Postal Code:
Phone Number:
Cell Phone:
Alternate Email Address:

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Sheet 4: 4. Pre-Training Information

Pre-Training Information
Previous Position
Position	Position Other	Title of this professional position	Institution or Company where this last professional position was held	Location of Institution or Company
Prior Academic Degrees
Degrees held before start of training (You can enter more than one degree, as applicable)	Country of the institution that granted the degree (please no acronyms)	Institution that granted the degree (please no acronyms)	Year the degree was awarded (YYYY)

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Sheet 5: 5. In Training Experience

In-Training Education (There are 3 sections on this tab. Please scroll down to make sure you review all 3.)
Trainees Research Project Title (e.g., name of Master’s Thesis or Post-Doctoral Project)	Date Training Began (may be different from when you entered Graduate School or Post-Doctoral Appointment) (MM/DD/YYYY)	Date Training Ended (may be different from when you entered Graduate School or Post-Doctoral Appointment) (MM/DD/YYYY)	Degree Level (Pre-Doc, Post-Doc)	NIH Field of Training
N/A	09/01/1996	12/31/1996	PRE-DOC	3240 - Toxicology
Scientific Technical Emphasis	Sources of Support
TOXICOLOGY
Research Training Mentor
Mentor’s First Name (required)	Mentor’s Last Name (required)	Country of Institution (required; please do not use acronyms)	Institution Name (required; please do not use acronyms)	Mentor’s Department (required)	Start Year of Mentoring (please enter date as YYYY)	End Year of Mentoring (please enter date as YYYY)
		UNITED STATES	UNIVERSITY OF MICHIGAN	ENVIRONMENTAL HEALTH SCIENCES
In-Training Education
(Please list all the degrees, certificates, or training completed while supported by the ES training program.)
Degree or Nature of Training (required; You can enter more than one degree, as applicable)	Country of the institution that granted the degree (please do not use acronyms)	Institution that granted the degree (please do not use acronyms)		When did the education program begin? (required; please enter date in MM/YYYY format)	When did the educational program end or when is it expected to end? (required;please enter date in MM/YYYY format)
PHD - DOCTOR OF PHILOSOPHY					Current

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Sheet 6: 6. Career Highlights

Accomplishments: Career Highlights
Please only enter accomplishments that can be attributed to T32-funded training.
Career Highlight / Leadership Year Began (required; YYYY)	Career Highlight / Leadership Year End (YYYY)	Career Highlight/Leadership Title (required)	Career Highlight / Leadership Narrative (required; please provide a descriptive title/name for the leadership event)	Training Status When Accomplished (required)

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Sheet 7: 7. Employment

Accomplishments: Employment
Please only enter accomplishments that can be attributed to T32-funded training.
Training Status While Employed In This Position (required; report your training status when you obtained employment)	Employment Year Began (required; YYYY)	Employment Year End (YYYY)	Job Title (required)	Country of Employment	Name of Employer	Employment Sector (required)	Major Emphasis of this Position (required)	Is this a Post-Doc Position? (required; Yes, No)	Tenure Status (required)	Topic Area for Position

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Sheet 8: 8. Fellowships

Accomplishments: Fellowship
Please only enter accomplishments that can be attributed to T32-funded training.
Training Status When Fellowship was Accomplished / Awarded (required)	Fellowship Name (required)	Awarding Institution or Agency (required)	Year Received (required; YYYY)	Associated Research Sponsor	Associated Research Sponsor - Other

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Sheet 9: 9. Honors Awards

Accomplishments: Honors/Awards
Please only enter accomplishments that can be attributed to T32-funded training.
Training Status when you Received/Accomplished the Honors/Awards (required)	Name of Honor/Award/Recognition (required)	Awarding Entity (name of the institution or agency that granted the honor or award)	Location of Awarding Entity (please list country only)	Year Received or Initiated (enter date as YYYY)

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Sheet 10: 10. New Competitive Funding

Accomplishments: New Competitive Funding
New Competitive Funding is for funding obtained after training has been completed. To record support during the training period, please add a Research Sponsor on the In-Training Experience page on Tab 5.
Trainee’s Role on Post-Training Funded Award	Start Date of Funded Award (required; MM/YYYY)	Title of Award (required)	Award Number	Name of Funding Organization (required)	Country Where Funding Organization is Located

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Sheet 11: 11. Post-Training Education

Accomplishments: Post-Training Education
Enter data about educational experiences obtained AFTER the trainee left the program. If the main degree program is captured in the In-Training section, please do not repeat it here. This area is for additional educational experiences, POST-DOC, Certificate Program, etc.
Country of the Institution Granting the Degree (required)	Name of Institution Granting the Degree (required)	Educational Degree or Nature of Training Program (required)	Year the Degree Earned (required; enter date as YYYY)

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Sheet 12: 12. Posters

Accomplishments: Posters at Scientific Meetings
Please only enter accomplishments that can be attributed to T32-funded training.
Training Status When Accomplished (required)	Year Poster Presented (required; YYYY)	Number of Posters Presented at Scientific Conferences that Year (required)

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Sheet 13: 13. Product or Policy Dev

Accomplishments: Product or Policy Development
Please only enter accomplishments that can be attributed to T32-funded training.
Training Status When Accomplished (required)	Resulted in the Development or Implementation of	URL or Citation for Product or Policy	Description of the Product or Policy (required)	Significance of the Product or Policy (required)	Year of Product or Policy Development (YYYY)	Resulted in a Non-provisional Patent (Yes, No)	Patent Number (Answer if awarded a non-provisional patent)	Country that Issued Patent	Demonstrable Effects on U.S. Health Science and Public Health Interventions (Yes, No)	Description of Significance of Effects on U.S. Health Science and Public Health Interventions

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Sheet 14: 14. Publications

Accomplishments: Publications

There are 3 tables on this page. Please make sure you scroll all the way down and review all 3 tables. Please enter publications that can be attributed to T32-funded training. This includes any work associated with a topic, method, tool or other direct experience from your appointment to this training grant. You may include articles published during or after your training grant appointment. Table 1 lists publications that are already in CareerTrac and have a Pubmed or Pubmed Central ID. Use Table 1 to add publications, AFTER you have reviewed Table 3 to identify any publications that CareerTrac has found for you. If you do not find your publications listed in Table 3, you need ONLY enter either the PMID or PMCID in Table 1 and the training status when accomplished (Column C) in this table. The system will automatically complete the rest of the information. Please note that only the most recent 10 articles are listed in Table 1. Table 2 lists publications in CareerTrac that were manually entered entered into the system. Please review these to ensure there is no overlap with the other tables and remove any duplicates. To add more publications that do not have Pubmed or Pubmed Central IDs, you should enter each new publication in a new row and complete the required fields, including training status when accomplished (Column C). It should be rare that you need to enter publications in this table. Table 3 lists publications that you may want to link to your record in CareerTrac. These were identified using our publication search protocol, based on your first and last name. Review this list and select Add (Column A) for any publications that you would like to add to CareerTrac. Select ignore if the publication is not associated with you or should not be linked to you in CareerTrac. Please include training status when accomplished (Column C).

Table 1. Publications Already in CareerTrac that have a PMID/PMCID (Please note that only the most recent 10 articles are listed in Table 1.)

First, review publications attributed to you: highlight any corrections to existing rows in this table. Then use this table to add publications, AFTER you have used Table 2 to review any publications that CareerTrac has found for you. If you do not find your publications listed in Table 2, you need ONLY enter either the PMID or PMCID and the training status when accomplished (Column C) in this table. The system will automatically complete the rest of the information.

Author Last, First Name (required)

Article Title

Training Status when Research Conducted (required)

PubMed ID (PMID)

PubMed Central ID (PMCID)

Local or International Readership (Local, International)

Country / Countries in Which Research Took Place

Table 2. Publications Manually Entered into CareerTrac that do not have a PMID/PMCID

Enter additional publications here when no Pubmed or Pubmed Central ID is available. This should be rare, because all peer reviewed publications should have a Pubmed Central ID to be compliant with NIH Publications policy. Enter each publication on a separate row. Please indicate your training status when the article was published (Column C).

If you have a PMID/PMCID, please enter the publication in Table 1.

Article Title (required)

Journal Name (required)

Training Status when Research Conducted (required)

Volume Number

Journal Publication Month

Journal Publication Year

First Author (Last Name, First Name; required)

Last Author (Last Name, First Name)

Other Author (Last Name, First Name)

PMID

PMCID

Peer Reviewed Article (Yes, No)

Local or International Readership (Local, International)

Country / Countries in Which Research Took Place

Table 3. Publications Found by CareerTrac based on Trainee Name - To ADD or IGNORE

Select "Add" in column A for each publication in this list that is, in fact, authored by you. Select "Ignore" if you are not an author. If you select Add, indicate the training status when the research in the article was conducted (Column C).

Add/Ignore

Article Title

Training Status when Research Conducted (required)

Journal Name

Publication Date

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Sheet 15: 15. Students

Accomplishments: Students
Please indicate the number of students the trainee has trained/educated in an area related to his/her NIEHS research training.
Year of Training (YYYY)	Number of students that you have trained or educated (required)	Training status when accomplished (required)