Form 1 AIP Feedback Collection Form

ACADEMIC INTERNSHIP PROGRAM (AIP) - FEEDBACK
OMB Number: 0925-0648
Expiration Date: 31 May 2021
The NIH Academic Internship Program (AIP) is designed to bring high school, community college,
and college students to the NIH Intramural Research Program throughout the academic year for
research. You have been identified as an NIH trainee that falls within these parameters, therefore,
the Office of Intramural Training & Education (OITE) wishes to collect your feedback on your current
experience and needs in order to support your research, academic, and career development.
NIH OITE
Website: http://www.training.nih.gov
Email: oite@mail.nih.gov
YouTube: https://www.youtube.com/c/NIHOITE/

GENERAL INFORMATION
Name Prefix:

Mr.

Ms.

Mx.

Rather Not Answer

First Name (Given Name):*

Middle Initial:

Last Name (Family Name):*

NIH Email Address:*

(check accuracy)
(If you don't have an NIH email address, enter 'N/A')
Personal Email Address:*

(check accuracy)
Phone Number:

(check accuracy)
What is your citizenship?*

US Citizen

US Permanent Resident

Foreign National

Are you at least 17 years of age?*

Yes

No
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EDUCATION INFORMATION 
I am currently a:*

Academic Institution Name:*

What is your current year at this education level?*

First Year

Second Year

Third Year

Fourth Year

Fifth Year

What is your Grade Point Average (GPA) based on a 4-point maximum scale?

During the internship, are enrolled and in good academic standing?

Yes

No

Is your school within 40 miles of the NIH campus on which you are interning or will intern?*

Yes

No

NIH INFORMATION 
What is your NIH badge number?:*

(10-digit number under the text 'personal identifier' on the back of the badge)
What is your NIH Institute-Center?*

On which NIH campus is your internship located?*

What year did you start training at the NIH?:*

What month did you start training at NIH?:*

NIH INVESTIGATOR INFORMATION 
NIH Investigator First Name (Given Name):*

NIH Investigator Last Name (Family Name):*

NIH Investigator Email Address:*

(check accuracy)

RELATIVE AT NIH DISCLOSURE INFORMATION 
Do you have relatives working in your specific NIH Institute-Center?*

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Yes

No

COMMENTS
How did you learn about internship opportunities during the academic year at the NIH?:

How did you learn about the OITE?:

Public reporting burden for this collection of information is estimated to average 20-minutes per
submission. 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 0925-0648. Do not return the completed form to this address.
Collection of this information is authorized by The Public Health Service Act, Section 410 (42 USC 285).
Rights of 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. 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 participants and reported as summaries.

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