3 SRP CareerTrac Data Collection Form

FIC CareerTrac

SRP CareerTrac Data Collection Form

Trainees

OMB: 0925-0568

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0925-0568 can be found here:

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CareerTrac Data Collection Form

Superfund Research Program (SRP) / National Institute of Environmental Health Sciences (NIEHS)

Hello!

The National Institutes of Health (NIH) is delighted to introduce you to CareerTrac, an information system developed to document and improve long term training program outcomes. CareerTrac collects, tracks, and reports information about NIH-supported trainees, such as trainee name, contact information, biographical information, training information, and subsequent career information. The system also supports tracking of trainees' accomplishments, such as fellowships, awards, employment, education, product or policy development, publications, funding received, presentations at conferences, and students mentored.

NIH uses this information to evaluate the long-term outcomes of training program investments and make recommendations for improvement. The information may be aggregated and disclosed with science officers, evaluators and administrators at NIH, and with other organizations such as DHHS, Congress and other organizations interested in NIH training investments and outcomes. Your training grant Principal Investigator (PI) and their administrator(s) also have access to this information; they are responsible for entering the data.

Collection of this information is authorized under 42 U.S.C. 241. The primary use of this information is to identify candidates for clinical and research fellow, clinical elective, and other training positions as well as to maintain a permanent record of those individuals who have received research training at the National Institutes of Health. NIH will take every reasonable precaution to protect your information. CareerTrac is securely hosted behind the NIH firewall; we maintain appropriate physical, electronic and procedural safeguards to ensure the security, integrity and privacy of your personal information.

As a trainee, providing information to CareerTrac is voluntary. NIH requires PIs to track trainees and provide trainee data for 10 years after a trainees’ appointment to a training grant. If you choose not to participate, your PI is still expected to enter information on your training experience and outcomes. If you have questions or concerns, please feel free to contact your PI directly or the CareerTrac Administrators: [email protected].

Thank you,

The CareerTrac Development Team

Respondent Burden Statement

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, 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 0925-0568

Do not return the completed form to this address.

This questionnaire includes the following sections:

Personal Information)…………………………………………...……………..................................................p. 4

This section contains questions regarding your personal information, including name and email address.

Contact Information………………………………………………………..…………………….………………………………p. 5

This section contains questions regarding your mailing address and phone number.

Pre-Training Information………………………………………..…………….……............................................p. 5

This section contains questions regarding your professional and educational history before your SRP funding / training

In-Training Experience Page…………………………………………………………………………………………………..p. 5

This section contains questions regarding your SRP-funded training experience. It also contains questions regarding the degree or certificate earned through your SRP-funded training, the start and end date of your funding period, and mentor data etc…

Accomplishments ……………………………………….………………………………………….…………………..………..p. 9

This section contains questions regarding your personal achievements that can be attributed to your SRP-funded training.

Instructions: To fill out each box, please type into the shaded gray box after each question.

Personal Information

1. First Name (required):

2. Middle Name:

3. Last Name (required):

4. Suffix (i.e. Jr., Sr., I.,):

5. Primary e-mail address (required):

6. Secondary e-mail address:

7. Gender (required):

8. Country of Origin:

9. Ethnicity (required for US Permanent Residents and US citizens only; Please indicate ethnicity, or choose not to specify; select one): Hispanic or Latino Not Hispanic or Latino Choose not to specify

Ethnicity Definitions as defined by the Office of Management and Budget (OMB)

Hispanic or Latino	A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term "Spanish origin" can also be used in addition to "Hispanic or Latino."
Not Hispanic or Latino	All other ethnicities
Choose not to specify	Not specified

10. Race: (required for US Permanent Residents and US citizens only)

American Indian or Alaskan Asian Black or African American Native Hawaiian or Pacific Islander

White Choose not to specify

Race Definitions as defined by the Office of Management and Budget (OMB)

American Indian or Alaskan	A person having origins in any of the original peoples of North, Central, or South America, and who maintains tribal affiliations or community attachment
Asian	A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. (NOTE: Individuals from the Philippine Islands have been recorded as Pacific Islanders in previous data collection strategies).
Black or African American	A person having origins in any of the black racial groups of Africa. Terms such as "Haitian"; or "Negro"; can be used in addition to "Black or African American";
Native Hawaiian or Pacific Isl.	A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
White	A person having origins in any of the original peoples of Europe, the Middle East, or North Africa
Choose not to specify	Not specified

11: Training Status (required; Select one): In-Training Post-Training

Contact Information

1. Address (include City, State/ Province, Country, Postal Code):

2. Work Number:

3. Home/Cell Phone Number (if the number is an international number, include country code, area or city code and local number):

Pre-Training Information

Please select the last professional position before entering the SRP training program (Select one:

Employee Faculty Fellow Self-Employed Student Other

If ‘other’, please specify:

Title prior to SRP Training Program:
Institution or Company prior to SRP Training Program (please do not use acronyms):
Country of Institution or Company:
Degrees held before start of training (required; You can select more than one degree, as applicable.):

Bachelor’s

Master’s

Other non-degree training (>=3 months; e.g., certificate, diploma, sabbatical)

Postdoctoral position (>= 3 months)

Professional Doctorate (e.g., medical doctor, dentist, pharmacist)

Research Doctorate (e.g., PhD, DPh, DSc)

Short Term Training (<3 months)

6. Country of the institution that granted the degree (please do not use acronyms):

7. Institution that granted the degree (please do not use acronyms):

8. Year the degree was awarded (YYYY):

In-training Experience

Date Entered Graduate School or Post-Doctoral Appointment (MM/YYYY):
Date Completed Graduate School or Post-Doctoral Appointment (MM/YYYY):
Date SRP Training Began (may be different from when you entered Graduate School or Post-Doctoral Appointment) (MM/DD/YYYY):
Date SRP Training Ended (may be different from when you completed Graduate School or Post-Doctoral Appointment) (MM/DD/YYYY):
Trainees Research Project Title (e.g., name of Master’s Thesis or Post-Doctoral Project):
NIH Field of Training (please select ONLY one from the following list):

1000 – Predominantly Non-Clinical or Lab-Based Research Training

1100 – Biochemistry

1110 – Biological Chemistry

1120 – Bioenergetics

1130 – Enzymology

1140 – Metabolism

1200 – Bioengineering

1210 – Bioelectric/Biomagnetic

1220 – Biomaterials

1230 – Biomechanical Engineering

1240 – Imaging

1250 – Instrumentation and Devices

1260 – Mathematical Modeling

1270 – Medical Implant Science

1280 – Nanotechnology

1290 – Rehabilitation Engineering

1310 – Tissue Engineering

1400 – Biophysics

1410 – Kinetics

1420 – Spectroscopy

1430 – Structural Biology

1440 – Theoretical Biophysics

1500 – Biotechnology

1510 – Applied Molecular Biology

1520 – Bioprocessing and Fermentation

1530 – Metabolic Engineering

1600 – Cell and Developmental Biology

1610 – Cell Biology

1620 – Developmental Biology

1700 – Chemistry

1710 – Analytical Chemistry

1720 – Bioinorganic Chemistry

1730 – Bioorganic Chemistry

1740 – Biophysical Chemistry

1750 – Medicinal Chemistry

1760 – Physical Chemistry

1770 – Synthetic Chemistry

1900 – Environmental Sciences

2000 – Genetics

2010 – Behavioral Genetics

2020 – Developmental Genetics

2030 – Genetic Epidemiology

2040 – Genetics of Aging

2050 – Genomics

2060 – Human Genetics

2070 – Molecular Genetics

2080 – Population Genetics

2200 – Immunology

2210 – Asthma and Allergic Mechanisms

2220 – Autoimmunity

2230 – Immunodeficiency

2240 – Immunogenetics

2250 – Immunopathology

2260 – Immunoregulation

2270 – Inflammation

2280 – Structural Immunology

2290 – Transplantation Biology

2310 – Vaccine Development

2400 – Microbiology and Infectious Diseases

2410 – Bacteriology

2420 – Etiology

2430 – HIV/AIDS

2440 – Mycology

2450 – Parasitology

2460 – Pathogenesis of Infectious Diseases

2470 – Virology

2600 – Molecular Biology

2800 – Neuroscience

2810 – Behavioral Neuroscience

2820 – Cellular Neuroscience

2830 – Cognitive Neuroscience

2840 – Communication Neuroscience

2850 – Computational Neuroscience

2860 – Developmental Neuroscience

2870 – Molecular Neuroscience

2880 - Neurochemistry

2890 - Neurodegeneration

2910 – Neuropharmacology

2920 – Sytems/Integrative Neuroscience

3100 – Nutritional Sciences

3200 – Pharmacology

3210 – Molecular Pharmacology

3220 – Pharmacokinetics

3230 – Pharmacogenetics

3240 – Toxicology

3300 – Physiology

3310 – Aging

3320 – Anesthesiology (basic science)

3330 – Endocrinology

3340 – Exercise Physiology (basic science)

3360 – Molecular Medicine

3370 – Physiological Optics

3500 – Plant Biology

3600 – Psychology, Non-Clinical

3610 – Behavioral Communication Sciences

3620 – Behavioral Medicine (non-clinical)

3630 – Cognitive Psychology

3640 – Developmental and Child Psychology

3660 – Mind-Body Studies

3680 – Neuropsychology

3690 – Personality and Emotion

3710 – Physiological Psychology & Phychobiology

3730 – Psychometrics

3740 – Psychophysics

3750 – Social Psychology

3900 – Public Health

3920 – Epidemiology

3930 – Health Economics

3940 – Health Education

3950 – Health Policy Research

3970 – Occupational and Environmental Health

4100 – Radiation, Non-Clinical

4110 – Nuclear Chemistry

4120 – Radiation Physics

4200 – Social Sciences

4210 – Anthropology

4220 – Bioethics

4240 – Economics

4250 – Education

4260 – Language and Linguistics

4270 – Sociology

4400 – Statistics and/or Research Methods and/or Informatics

4410 – Biostatistics and/or Biometry

4430 – Computational Science

4440 – Information Science

4600 – Trauma, Non-Clinical

6000 – II. Predominantly Clinical Research Training (can include any degree)

6100 – Allied Health

6110 – Audiology

6120 – Community Psychology

6130 – Exercise Physiology (clinical)

6150 – Occupational Health

6160 – Palliative Care

6170 – Physical Therapy

6190 – Social Work

6210 – Speech-language Pathology

6400 – Dentistry

6500 – Clinical Disciplines

6510 – Allergy

6520 – Anesthesiology

6540 – Cardiovascular Diseases

6550 – Clinical Laboratory Medicine

6560 – Clinical Nutrition

6570 – Clinical Pharmacology

6590 – Clinical Psychology

6610 – Connective Tissue Diseases

6620 – Dermatology

6630 – Diabetes

6640 – Gastroenterology

6660 – Immunology

6670 – Gene Therapy (clinical)

6690 – Hematology

6710 – HIV/AIDS

6830 – Liver Diseases

6840 – Metabolic Diseases

6860 – Neurology

6870 – Opthalmology

6890 – OB-GYN

6910 – Oncology

6920 – Orthopedics

6940 – Preventative Medicine

6950 – Radiation, Interventional

6970 – Radiology, Diagnostic

6980 – Rehabilitation Medicine

6690 – Psychiatry

7120 – Trauma

7130 – Urology

7300 – Pediatric Disciplines

7320 – Pediatric Hematology

7330 – Pediatric Oncology

7340 – Pediatric, Prematurity & Newborn

7500 – Nursing

7700 – Veterinary Medicine

8000 – Other, Predominantly Clinical Research Training

3350 – Integrative Biology

3380 – Reproductive Physiology

3650 – Experimental & General Psychology

3720 – Psychology of Aging

3910 – Disease Prevention and Control

3960 – Health Services Research

4130 – Radiobiology

4230 – Demography & Population Studies

4420 – Bioinformatics

4450 – Clinical Trials Methodology

6140 – Medical Genetics

6180 – Pharmacy

6211 – Rehabilitation

6530 – Behavioral Medicine (clinical)

6580 – Complementary and Alternative Medicine

6650 – Endocrinology

6680 – Geriatrics

6820 – Infectious Diseases

6850 – Nephrology

6880 – Nuclear Medicine

6930 – Otorhinolaryngology

6960 – Pulmonary Diseases

7110 – Surgery

7310 – Pediatric Endocrinology

5000 – Other, Predominantly Non-Clinical or Lab-Based Research Training

Training Core Leader (ONLY for P42 grants; if your Center has a Training Core Leader, please list them here. For R01 grants, leave blank. First Name Last Name):
Subproject ID (ONLY for P42 Grants; this is the Project Number listed in the original grant application. For R01 grants, leave blank):
Subproject Title (ONLY for P42 Grants, this is the Project Title listed in the original grant application. For R01 grants, leave blank):
Honors (please check all that apply):

KC Donnelly Award

SRP Annual Meeting Poster Winner

SRP Annual Meeting Speaker

Wetterhahn Award

Scientific Technical Emphasis (Select up to six fields that describe your research).

g. Country where funding organization is located:

7. Posters at Scientific Meetings

a. Training status when accomplished (required):

Pre-training In-training Post-training

b. Year poster presented (required; YYYY):

c. Number of posters given at scientific conferences that year (required):

8. Product or Policy Development

a. Training status when accomplished (required):

Pre-training In-training Post-training

b. Did any of your work on this grant result in the development or implementation of the following? (From the list provided, choose the most applicable. If you select “other” please enter brief description in the space provided):

OMB NO.: 0925-0568

Expiration Date: 9/30/2012

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	Trainee personal information
Author	cordtsab
File Modified	0000-00-00
File Created	2021-01-30

Article Title (required):
Journal name (required):
Volume Number:
Pages:
Journal publication date (MM/YYYY):	Month: Year:	Month: Year:	Month: Year:	Month: Year:
First author (Last name, first name; required):
Last author (enter the name of article’s last author in Last name, first name format):
Other authors (separated by a semi-colon in Last name, first name format):
PMID number
PMCID number
Has this article been Peer Reviewed?	YES NO	YES NO	YES NO	YES NO
Training Status when Research Conducted:	Pre-training In-training Post-training	Pre-training In-training Post-training	Pre-training In-training Post-training	Pre-training In-training Post-training
Indicate whether the journal has a local or international readership and/or distribution:	Local International	Local International	Local International	Local International
Country/countries in which research described in the article took place: