Form 11 NIH NHMA Feedback Form

OMB #0925-0748
Expiration Date 12/2019
NIH/NHMA Feedback Form
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Academic Career Development Workshop

* 1. Please rate the following:
Poor Fair Good Very Good Excellent
Early Years in Academia: Diversity Supplements
Speaker
Comments:

Early Years in Academia: NIH Loan Repayment Program (LRP)
Speaker
Comments:

Early Years in Academia: LRP for Health Disparities Research
Speaker
Comments:

Navigating the NIH Grant Application and Peer Review Processes
Speaker
Comments:

Lunch
Comments:

Biomedical Research Careers Talk
Speaker

N/A

Poor Fair Good Very Good Excellent

N/A

Comments:

Understanding the Tenure Process for Success in Academic Medicine
Speaker
Comments:

* 2. What other topic areas would be particularly useful for you that was not covered during the workshop?

* 3. What components of the Academic Career Development Workshop did you think were most helpful?

* 4. What components of the Academic Career Development Workshop did you think were least helpful?

* 5. What components of the Academic Career Development Workshop would you change and how?

* 6. Overall, did the workshop meet your expectations?
Below expectations
Met expectations
Exceeded expectations

* 7. How likely are you to pursue a career in academic medicine?
Unlikely
Somewhat unlikely
Undecided
Somewhat likely
Extremely Likely

* 8. How would you rate the influence of the Academic Career Development Workshop on your previous
response?
Very little influence
Some influence
Great deal of influence
Unsure

9. Any other comments?

Research Funding & Membership

* 10. To date, have you been supported by an NIH grant or contract?
Yes
No

* 11. Have you every applied for an NIH funding opportunity but were not awarded?
Yes
No

* 12. Are you a member of the National Hispanic Medical Association?
Yes
No

* 13. Does participation in this workshop make you more likely to become a member if not a member
already?
Yes
No

Demographic Information

* 14. How would you classify your current career status?
Resident
Fellow
Instructor
Assistant Professor
Post-doctoral Researcher
Other (please specify)

* 15. What is your primary specialty?

* 16. How would you describe your gender?
Male
Female
Prefer not to answer
Other (please specify)

* 17. Which of these best describes your ethnicity (choose one)?
Hispanic or Latino
Not Hispanic or Not Latino

* 18. Which of these best describes your race (choose one or more)?
African American/Black
American Indian/Alaska Native
Asian
Native Hawaiian/Pacific Islander
White
Other (please specify)

Thank you for your feedback!
Stay in touch and let us know how we can be partners in your career development.