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pdfUGSP EVALUATION OF SCHOLAR PAYBACK PERIOD
OMB Number: 0925-0299
Expiration Date: 30 May 2024
Burden Time: 10 minutes
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 10-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 0925-0299. Do not return the completed form to this address.
Q1 First Name (Given Name):
________________________________________________________________
Q2 Last Name (Family Name)
________________________________________________________________
Q3 Type of Service Completed
o Summer Service
o Year Service
Q4 Service Period Start Date (ex: 15 Jun 2024)
________________________________________________________________
Q5 Service Period Stop Date (ex: 15 Aug 2024)
________________________________________________________________
Page 1 of 3
Q6 Indicate the strengths of this scholar using these categories:
Top 1%
Top 10%
Top 33%
Top 50%
Bottom 50%
N/A
Interest in
Science
o
o
o
o
o
o
Ability to
Complete
Projects
Accurately and
Timely
o
o
o
o
o
o
Writing Skills
o
o
o
o
o
o
Analytical
ProblemSolving Skills
o
o
o
o
o
o
Oral
Communication
Skills
o
o
o
o
o
o
Ability to Work
Independently
o
o
o
o
o
o
Rapport with
Peers
o
o
o
o
o
o
Rapport with
Faculty or
Supervisor
o
o
o
o
o
o
Initiative
o
o
o
o
o
o
Curiosity
o
o
o
o
o
o
Creativity
o
o
o
o
o
o
Observation
Skills
o
o
o
o
o
o
Q7 Assess the scholar's potential for a career in biomedical research and share any observation and inferences that would be useful
in predicting this scholar's potential to become a biomedical, behavioral, or social science health related researcher.
________________________________________________________________
________________________________________________________________
________________________________________________________________
Q8 Do you have any reason to believe this scholar may not satisfy the post-graduation service requirement?
________________________________________________________________
________________________________________________________________
________________________________________________________________
Page 2 of 3
EVALUATOR INFORMATION
Q9 First Name (Given Name)
________________________________________________________________
Q10 Last Name (Family Name)
________________________________________________________________
Q11 Email Address (check accuracy)
________________________________________________________________
Q12 Signature Block
________________________________________________________________
________________________________________________________________
________________________________________________________________
Page 3 of 3
| File Type | application/pdf |
| File Title | F07-UGSP-Evalution-Scholar-Payback-Period |
| Author | Wagner, Patricia (NIH/OD) [E] |
| File Modified | 2024-01-13 |
| File Created | 2024-01-13 |