Form 1 Survey

1. CRCC Survey-OMB#: 0925-0458, Exp: 11/30/2010
Burden Disclosure Statement: Public reporting burden for this collection of information is estimated to average 30
minutes per survey, 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 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 (0925-0486). Do not return the completed form
to this address.
Please complete this voluntary survey on the Clinical Research Curriculum Certificate and its impact on your career.
We welcome your feedback and appreciate your honesty.

1. Please identify the year you completed your certificate.
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1999

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2000

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2001

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2002

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2003

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2004

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2005

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2006

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2007

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2008

2. Please rate the following question.

On a scale of 1-5
(1=none,

No impact

Small impact

Moderate impact

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5=considerable), please
indicate the impact this
program has had on your
professional career.

3. Please provide the following contact information.
Name:
Company:
Address:
Address 2:
City/Town:
State:
ZIP/Postal Code:
Country:
Email Address:
Phone Number:

Substantial

Considerable

impact

impact

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n

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N/A

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4. Please provide an alternative email.

5. What professional degrees do you hold?

6. Are you currently performing clinical research?
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Yes

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No

Other (please specify)

7. What is your professional title?

8. What organization and/or department do you work for?

9. What is your primary field of concentration?

10. What is your academic status?

11. What is your current appointment?

12. What are your funding sources?
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None

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K01-Mentored Research Scientist Development

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K08-Mentored Clinical Scientist Development

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K12-Mentored Clinical Scientist Development

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K22-Career Transition Award

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K23-Mentored Patient Oriented Research

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K24-Midcareer Investigator Award in Patient Oriented Research

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K30-Clinical Research Curriculum Award

Other (please specify)

13. What is the dollar amount of your grant(s)?
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None

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Less than $50,000

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$50,001-$100,000

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$100,001-$250,000

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$250,001-$500,000

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$500,001-$1,000,000

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Greater than $1,000,000

Other (please specify)

14. Please list your publications.

2. Performance Indicators
Please answer the following optional questions.

1. What could the Office of Clinical Research Training and Medical Education improve
on regarding the content of the Clinical Research Curriculum Certificate program?
Please be specific.

2. What are the most important clinical research challenges facing you in your career
this year?

3. Please provide any additional comments.