Form 1 Asthma Research Survey

Attachment 1

Survey Instrument

Form Approved

OMB No. 0925-xxxx

Exp. Date xx/xx/xxxx

ASTHMA RESEARCHER SURVEY

Demographics and General Information

Please indicate which sources of asthma-related funding you have had during your career to date.

Funding Source	Please check all sources of asthma-related funding (Please select all that apply) Career Last 10 years	Please check the primary (highest dollar value) source of asthma-related funding (Please select only one) Career Last 10 years
NIEHS	 	 
NHLBI	 	 
NIAID	 	 
NICHD	 	 
Other NIH	 	 
CDC	 	 
AHRQ	 	 
FDA	 	 
EPA	 	 
HUD	 	 
NSF	 	 
Other US government (not listed above)	 	 
Foundations	 	 
Industry	 	 
University discretionary/ start-up funds	 	 
Local, state or regional government	 	 
Other, specify__________________	 	 

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 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-xxxx). Do not return the completed form to this address.

For your NIH-funded asthma research, please indicate which types of funding you have received. (Please check all that apply).

 Research (e.g., R01, R03, R21)

 Program/Center (e.g., M, P and U awards)

 Career Development Individual (e.g., K awards; R23, R29)

 Fellowships (e.g., F awards)

 Institutional Training (e.g., T32)

 Technology Development (e.g., SBIR, STTR; R41-44, N43-44, U43-44)

 Other funding type (specify): _______________________________________

In what type of research do you engage? (Please check all that apply)

 Basic Science 	What types of basic research? (Please check all that apply)  Biochemistry  Biophysics  Botany  Cellular biology  Genetics  Ecology  Immunology  Medicine  Microbiology  Molecular biology  Physiology  Environmental Sciences  Other please specify________
 Applied Science 	What types of applied research? (Please check all that apply)
	 Clinical Research  Public Health Research  Health Services Research  Program or Policy Research  Technology Innovation Translational Research Intervention Research  Other please specify________

What is your age?

 <30

 30-39

 40-49

 50-59

 60+

What degrees do you hold? (Please check all that apply)

 AB, BA, BS, BSc

 MA, MS, MHS, MPH, MPA, MED, MSIH

 PhD, Sc.D, DSc

 MD

 Other clinical degree (e.g. DO, DDS, MBBS, RN)

 Other please specify_______________

 None

In what year did you receive your highest degree? _______________ (drop down menu)

Outputs

Please indicate which of the following mechanisms you have used to disseminate asthma-related knowledge and products stemming from your research. (Please check all that apply).

• Published in peer-reviewed journals

• Presented at scientific conferences

• Participated in grantee meetings

• Developed and disseminated curricula

• Developed and disseminated interventions

• Participated in the development of clinical guidelines for the treatment of asthma

• Developed and disseminated research tools and methods

• Participated in workshops or trainings disseminating your research

• Provided scientific testimony and briefings to legislators

• Developed and published websites

• Presented research in community forums

• Developed fact sheets and pamphlets

• Provided information for press releases

• Other, please specify:__________________________________________________

As part of your asthma-related research, you may have had the opportunity to engage with different types of individuals and groups. Please indicate what the nature of your personal engagement has been with each of the following groups. (Please check all that apply)

Group	Share information	Conduct joint projects or activities	Serve on boards or advisory panels	Provide formal testimony	Serve as employee or consultant	No interaction
Other researchers						
University administration / program directors						
Local, regional or national health officials						
Environmental regulators						
Food and drug regulators						
Legislators and staffers						
Business and industry representatives						
Housing and urban development agencies						
Advocacy groups						
Community groups						
Other : _________________________________________						

Commercialization

We are interested in whether your asthma-related research, regardless of funding source, has led to the development of intellectual property.

Have you applied for one or more patents?

 Yes  No

[IF YES] Have you received a patent?

 Yes  No

[IF YES] What is the nature of your innovation(s)?

• New drug

 New use of drug

 Medical product or device

• Environmental controls and services

• New process or procedure

• New research method

• New gene

• Other please specify _______________________________

Have you commercialized your innovation based on your patent(s)?

 Yes  No

Have you licensed your innovation(s)?

 Yes  No

Did any Federal agencies support this work?

 Yes  No

[IF YES] Which Federal agencies supported this work?

(Please check all that apply)

NIEHS	
NHLBI	
NIAID	
NICHD	
Other NIH	
CDC	
AHRQ	
FDA	
EPA	
HUD	
NSF	
Other US government (not listed above)	

Have you spun-off or started a new company?

 Yes  No

Potential Impacts

We are interested in your perspective on the use of your asthma-related research to affect long term asthma outcomes (now or in the near future) through a variety of pathways, including clinical practice changes, reduced environmental emissions, reduced exposure to environmental hazards, or changes in public behavior and advocacy. For each of the following items, please mark the ’current’ box if you believe your research has already affected change in this area and the ‘future potential’ box if you believe it has the potential to affect change in the next 10 years.

Impact Area	Impact Timing
a. My research has led to greater understanding of asthma disease mechanisms	Current Future potential
b. My research has led to greater understanding of individual, social, and environmental factors associated with asthma	Current Future potential
c. My research has led to improved environmental measurement techniques	Current Future potential
d. My research has led to increased evidence regarding effective interventions	Current Future potential
e. My research has led to improved environmental control techniques	Current Future potential
f. My research has led to changes in curriculum for clinical/public health students	Current Future potential
g. My research has led to changes in curriculum for K-12 or families	Current Future potential
h. My research has led to changes in business practices regarding indoor air	Current Future potential
i. My research has led to changes in business practices regarding outdoor air	Current Future potential
j. My research has led to changes in environmental standards or regulations for indoor air	Current Future potential
k. My research has led to changes in environmental standards or regulations for outdoor air	Current Future potential
l. My research has led to changes in public health/environmental legislation related to asthma	Current Future potential
m. My research has led to changes in clinical guidelines for asthma	Current Future potential
n. My research has led to changes in clinical practice relevant to asthma	Current Future potential
o. My research has led to changes in public knowledge and practices related to asthma prevention and control	Current Future potential
p. My research has led to increased public advocacy for asthma prevention and control	Current Future potential

Program so that for each item above with a mark of current or future impact (except items a-c), they are asked a follow-up question about their personal involvement in activities designed to further this impact.

You indicated that your research has already or has the potential to have an effect on each of the impact areas listed below. We are also interested in whether you personally are or have been involved in activities designed to achieve that type of impact or whether that is not a role that you have taken.

I am (or have been) personally involved in activities that are designed to further each of the following goals (yes or no).

Impact Area 1 (e.g., effective interventions)	Yes No
Impact Area 2 (e.g., clinical guidelines)	Yes No
Impact Area 3 (e.g., public advocacy)	Yes No

Etc…

Research Agenda

What asthma-related research topics would you like to see included among the NIEHS extramural research priorities over the next 5-10 years?_________________________________________

_____________________________________________________________________________