Form 11 NMA Academic Career Development Workshop Contact Info an

NIH/National Medical Association (NMA) Academic Career Development
Workshop Contact Information and Feedback Form

For past recipients of the NIH/NMA travel award, please provide the most up-to-date
contact information and feedback.

OMB No: 0925-0748
Expiration date: XX/XX/XXXX
Collection of this information is authorized by The Public Health Service Act,
Section 411 (42 USC 285a). Rights of study participants are protected by The Privacy
Act of 1974. Participation is voluntary, and there are no penalties for not
participating or withdrawing from the study at any time. Refusal to participate will
not affect your benefits in any way. The information collected in this study will be
kept private to the extent provided by law. Names and other identifiers will not
appear in any report of the study. Information provided will be combined for all
study participants and reported as summaries. You are being contacted by an on-line
website to complete this instrument so that we can obtain updated contact
information.
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 0MB 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 (0925-0748). Do
not return the completed form to this address.
* 1. Contact information:
Name
Institution/Organiza
tion
Position Title
Business Address
City/Town
State/Province
ZIP/Postal Code
Email Address
Phone Number

NIH/National Medical Association (NMA) Academic Career Development
Workshop Contact Information and Feedback Form

2. Is your current position in academic medicine or biomedical research?
Yes
No
Other (please specify)

NIH/National Medical Association (NMA) Academic Career Development
Workshop Contact Information and Feedback Form

3. Did attending the NIH/NMA Academic Career Development Workshop influence your
decision in pursuing a career in academic medicine or biomedical research?
Yes
No
Other (please specify)

NIH/National Medical Association (NMA) Academic Career Development
Workshop Contact Information and Feedback Form

4. What aspects of the NIH/NMA Academic Career Development Workshop were most
valuable to you (e.g., session topics, networking, small group discussions with NMA faculty,
etc.)?

NIH/National Medical Association (NMA) Academic Career Development
Workshop Contact Information and Feedback Form

Thank you for providing us with your updated information and feedback!