20 UGSP Payback Feedback Mentor

UNDERGRADUATE SCHOLARSHIP PROGRAM (UGSP) ‐ EVALUATION FOR PAY‐BACK
OMB Clearance Number: 0925-0299
Expiration Date: 30-Jun-2022

UGSP SCHOLAR INFORMATION
UGSP Scholar First Name

UGSP Scholar Last Name

Type of Service

Scholar's Period of Service ‑ Start Date

Scholar's Period of Service ‑ Stop Date

EVALUATION OF SCHOLAR
Interest in Science

Ability to Complete Projects Accurately and Timely

Writing Skills

Analytical Problem‑Solving Skills

Oral Communication Skills

Ability to Work Independently

Rapport with Peers

Rapport with Faculty or Supervisor

Initiative

Curiosity

Creativity

Observation Skills

Please assess the scholar's potential for a career in biomedical research and share any
observations and inferences that would be useful in predicting this scholar's potential to
become a biomedical, behavioral, or social science health‑related researcher. For
example, your comments may include your assessment of some of the following
attributes: scientific aptitude, creativity, curiosity, initiative, work habits, and peer
relationships.

Do you have any reason to believe that the scholar may not satisfy the post‑graduation
service requirement?

If you feel this UGSP scholar will not satisfy the post‑graduation service requirement,
please explain.

EVALUATOR'S INFORMATION
First Name (Given Name):*

Last Name (Family Name):*

Email Address (check accuracy):*

Institute‑Center:*

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.
Public reporting burden for this collection of information is estimated to average 15 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 (0925-0299). Do not return the
completed form to this address.