Form 1 Funding Source Questionnaire

OMB #: 0925-xxxx

Expiration Date: xx/xxxx

Attachment 1: Funding Source Questionnaire

In [YEAR OF ARTICLE PUBLISHED] you published an article titled: [TITLE OF ARTICLE] in [NAME OF JOURNAL].

1. Was your published article based on a study that received any funding?

 Yes  No [If NO, TERMINATE]  You have completed the questionnaire. We thank you for your time. If you have questions about this study or your participation, please contact Dr. Amanda Greene by email at [email protected] or by phone at (301) 496-9601.

2. Name of Funding Agency or Organization

If your published article was based on more than a single funded study, name all agencies that funded those studies.

1. Funding Agency or Organization 1

 Don’t Know/Don’t Remember

2. Funding Agency or Organization 2

 Don’t Know/Don’t Remember

3. Funding Agency or Organization 3

 Don’t Know/Don’t Remember

3. Type of Funding Source

For each funding agency or organization listed in Question 2, please select the type of funding source.

1. Funding Source 1 [drop down box]

 U.S. Government Funding

 Academic Institution

 Private Foundation

 Commercial Entity

 Professional Organization

 State/local Government

 Other National Government

 Other [please specify]

 Don’t Know/don’t remember

2. Funding Source 2 [refer to drop down box response options above]

3. Funding Source 3 [refer to drop down box response options above]

The following questions are about the studies that were funded by each funding agency that you listed previously.

4. Name of Funded Study

Please name all studies funded by:

1. Funded Study Name 1

 Don’t Know/Don’t Remember

2. Funded Study Name 2

 Don’t Know/Don’t Remember

3. Funded Study Name 3

 Don’t Know/Don’t Remember

5. Start Year of Funded Study

Select start year for each study listed in Question 4.

1. Start Year of Funded Study 1 [drop down box]

 Before 1997

 1998

 1999

 2000

 2001

 2002

 2003

 2004

 2005

 2006

 2007

 2008

 2009

 2010

 Don’t Know/Don’t Remember

2. Start Year of Funded Study 2 [refer to drop down box response options above]

3. Start Year of Funded Study 3 [refer to drop down box response options above]

6. Duration of Funded Study

Approximate length of each study listed in Question 4.

1. Duration of Funded Study 1 [drop down box]

 1 year or less

 2 years

 3 years

 4 years

 More than 5 years

 Don’t Know/Don’t Remember

2. Duration of Funded Study 2 [refer to drop down box response options above]

3. Duration of Funded Study 3 [refer to drop down box response options above]

7. Please enter any additional comments, information, or questions you would like to share with NINR:

You have completed the questionnaire. We thank you for your time. If you have questions about this study or your participation, please contact Dr. Amanda Greene by email at [email protected] or by phone at (301) 496-9601.

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