1 Recruitment and Screening Form

Facebook and LinkedIn Recruitment Message for Potential Medical/Dental/Veterinary Student Focus Group Participants

Share your perspectives on career decision-making by participating in a telephone-based focus group sponsored by the National Institutes of Health. A token of appreciation for participation will be offered. If interested, please respond by email to [email protected].

Twitter Recruitment Message for Potential Medical/Dental/Veterinary Student Focus Group Participants

Participate in an NIH-sponsored focus group about career decisions. Email your interest to [email protected].

Form Approved

OMB Number 0925-0648

Expiration Date 1/31/2015

Email-based Screening Tool for Potential Medical/Dental/Veterinary Student Focus Group Participants

Thank you for your interest in participating in a telephone-based focus group being sponsored by the National Institutes of Health. To help us determine your eligibility for the study, please respond to the following questions:

1. What is your name? ___________________________________

2. What medical/dental/veterinary school do you currently attend? _________________

3. What year do you expect to graduate with an MD/DDS/DVM degree? ____________

4. What is your primary career objective? (check all that apply): ____ patient care ___ private practice ____ academic medicine ___ clinical research ____ laboratory-based research ____combined research/clinical or academic medicine

5. When would be the best time for you to participate in a telephone focus group?

   1. Weekdays: ____ morning ____ afternoon ____ evening

   2. Weekends: ____ morning ____ afternoon ____ evening

6. What is your area code and telephone number: (____)____________ Landline (___)_____________ Cell

Thank you. We will let you know if you have been selected to participate in a focus group in the near future.

Public reporting burden for this collection of information is estimated to average 5 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 (0925-0648). Do not return the completed form to this address.

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