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EXP. XX/XXXX
Attachment 12:
BUILD Student Annual Follow-up Survey
OMB #0925-XXXX
EXP. XX/XXXX
BUILD Student Annual Tracking Survey
You have been selected to be a part of a national study on student experiences. Your
university, , is involved in a large effort funded by the National
Institutes of Health (NIH) to support students and faculty in biomedical, behavioral, clinical,
and social science fields. This effort, the NIH Diversity Consortium, is seeking to understand
what programs and strategies benefit students interested in these careers to inform funding
and programs. By taking time to complete this survey, you will help increase knowledge and
improve education for the next generation of students
The University of California, Los Angeles (UCLA) will be collecting information about these
programs. For some analyses, it will be important to compare students and faculty in
biomedical majors at Name of institution to those at other institutions as well as students
and faculty interested in other fields.
has provided UCLA your name and contact information because you
have participated in activities on your campus that are part of the NIH Diversity
Consortium’s work. All of the information you provide will be protected and secured to the
extent permitted by law.
Public reporting burden for this collection of information is estimated to average 25 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.
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Next
Cancel
OMB #0925-XXXX
EXP. XX/XXXX
A. Current position
First, we would like to ask you about any current school or work activities.
1. Last year, you told us you were ______ level at ______ institution. Has that
changed?
No
Yes and I am still in school
Yes and I am not still in school
a. Level:
Undergraduate
Graduate or other post-baccalaureate
Expected completion date (year): _____
b. Status:
Full Time
Part Time
c. Institution: _________________
d. Major: _________________
e. Please tell us your current status
I graduated from my previous institution
I did not graduate but do have plans to attend school in the next 2 years
I did not graduate and do NOT have plans to attend school in the next 2 years
OMB #0925-XXXX
EXP. XX/XXXX
2. Now we would like to ask you about any employment or internships. Last year, you
told us you were ____ at _____. Has that changed?
No
Yes
a. Please review the list below and check all that apply.
Working (including internships and significant volunteer positions)
Retired
Unemployed, looking for work
Otherwise not in labor force
Other (specify): _________________
b. Paid Employment (check all that apply):
Full Time
Part Time
Internship or student placement
Seasonal (full-time or part-time)
No paid employment
c. Is this paid position related to research?
No
Yes
d. Is this new job/position considered a promotion or advancement?
No
Yes
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OMB #0925-XXXX
EXP. XX/XXXX
e. Volunteer
Position: _________________
Company: _________________
No volunteer position
f. Is this volunteer position related to research?
No
Yes
3. During the past year, did you complete any degree or certificate program?
No
Yes
If yes, please indicate the following:
a. Degree / certificate: _________________
b. Major / area of study: _________________
c. From which institution or school: _________________
d. Date awarded: MM / YR
4. During the past year, did you apply to any degree or certificate program?
No
Yes
If yes, please indicate the following:
a. Degree / certificate the program awards: _________________
b. Major / area of study: _________________
c. Institution: _________________
d. Date applied: MM / YR
OMB #0925-XXXX
EXP. XX/XXXX
e. Status of application:
Accepted and will attend
Accepted and will not attend
Waitlisted
Pending
Not accepted
5. During the past year, did you receive any scholarships or grants for education
expenses that you do not need to repay?
No
Yes
If yes, please indicate the following:
a. Name of scholarship/grant: ______________________________
b. Amount (total value including value of any fee/tuition waivers):
Less than $1,000
$1,000-4,999
$5,000-9,999
$10,000 or more
c. Period of award: MM/YYYY to MM/YYYY
d. Was this award based on:
Need
Merit
Need and Merit
Other (specify): ________________
OMB #0925-XXXX
EXP. XX/XXXX
6. Do you have any education debt?
No
Yes
If yes, please indicate the following:
a. Total amount that you owe:
Less than $5,000
$5,000-9,999
$10,000-19,999
$20,000 or more
I don’t know how much I owe
b. How much you borrowed during the past year:
Less than $1,000
$1,000-4,999
$5,000-9,999
$10,000 or more
7. Please attach your most recent academic vita (such as a CV)
Upload
8. Please tell us which of the following activities you participated in since last time?
Check all that apply.
Other tuition or stipend program
Other summer program (i.e. Summer Research Experience)
Academic Advising and Support (i.e. tutoring, STEM advising, math courses, etc.)
Mentoring
Research training (i.e. workshops, training, field experience, conferences, etc.)
Other career advancement programs (i.e. networking, Professional Exposure, GRE Prep, field
trips, career panels, applications)
OMB #0925-XXXX
EXP. XX/XXXX
9. In the past year, have you participated in a pre-professional or departmental club?
No
Yes
10. To allow us to follow your professional accomplishments, please provide any of the
following identifiers that you may have:
a. ORCID _________________
I do not have one
b. NIH eRA Commons ID ___________________
I do not have one
c. LinkedIn ID _______________________
I do not have one
B. Mentoring
This next section concerns your experiences with mentoring in a variety of contexts.
A mentor is someone who provides guidance, assistance, and encouragement on professional
and academic issues. A mentor can be either someone who is more experienced (or senior)
than you or someone who is at a level similar to you (a “peer”).
A mentee is someone who receives guidance or assistance from a mentor. A mentee can be
someone less experienced (or junior) than you or someone who is your peer.
A mentoring relationship can be formal (with a set schedule and perhaps arranged by your
institution) or informal.
11. Do you have a faculty member or someone else who is more senior than you who
you consider a mentor?
No
Yes
OMB #0925-XXXX
EXP. XX/XXXX
a. How many different mentors do you regularly work with? ______
b. For the mentor you work with most closely (your primary mentor), please provide
the following information:
Position: ____________________________
Institution/ Company: __________________________
Discipline: ___________________________
c. Which of the following does your primary mentor help you with? (choose all that
apply)
Research, general (e.g. guidance related to finding literature, research techniques, and
selecting a research topic)
Research, specialized issues (e.g. just on statistics or instrumentation)
Educational choices and strategies (e.g., guidance in selecting coursework, further
educational opportunities
Career planning (e.g. giving advice, helping find opportunities)
Emotional support (e.g. listening to personal concerns)
Other (specify): ________________________________
d. How do you usually communicate with your primary mentor?
In-person
Phone/Skype
Email/Text
Other (specify): ______________
e. How often do you usually communicate with your primary mentor about your
research?
Weekly or more often
OMB #0925-XXXX
EXP. XX/XXXX
Monthly
Several time a year
Annually or less
f. How did you find this mentor?
Through your local campus
They were assigned in some other way by your department or campus
You were matched through the National Research Mentoring Network (NRMN)
Matched through some other formal program
You sought out your mentor independently
Other (specify): ______________
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OMB #0925-XXXX
EXP. XX/XXXX
12.Please rate how skilled you feel your primary mentor was in the following areas:
Not at all
Extremely
a. Active listening
1
2
3
4
5
6
7
N/A
b. Providing constructive feedback
1
2
3
4
5
6
7
N/A
c. Establishing a relationship based on trust
1
2
3
4
5
6
7
N/A
d. Identifying and accommodating different
communication styles
1
2
3
4
5
6
7
N/A
e. Employing strategies to improve
communication
1
2
3
4
5
6
7
N/A
f. Coordinating effectively with other mentors
with whom you work with
1
2
3
4
5
6
7
N/A
g.Working with you to set clear expectations
of the mentoring relationship
1
2
3
4
5
6
7
N/A
h. Aligning his/her expectations with your own
1
2
3
4
5
6
7
N/A
i. Considering how personal and professional
differences may impact expectations
1
2
3
4
5
6
7
N/A
j.Working with you to set research goals
1
2
3
4
5
6
7
N/A
k. Helping you develop strategies to meet
goals
1
2
3
4
5
6
7
N/A
l. Accurately estimating your level of scientific
knowledge
1
2
3
4
5
6
7
N/A
m. Accurately estimating your ability to
conduct research
1
2
3
4
5
6
7
N/A
n. Employing strategies to enhance your
understanding of the research
1
2
3
4
5
6
7
N/A
o. Motivating you
1
2
3
4
5
6
7
N/A
p. Building your confidence
1
2
3
4
5
6
7
N/A
q. Stimulating your creativity
1
2
3
4
5
6
7
N/A
r Acknowledging your professional
contributions
1
2
3
4
5
6
7
N/A
s. Negotiating a path to professional
independence with you
1
2
3
4
5
6
7
N/A
t. Taking into account the biases and
prejudices s/he brings to your mentor/mentee
relationship
1
2
3
4
5
6
7
N/A
OMB #0925-XXXX
EXP. XX/XXXX
u. Working effectively with mentees whose
personal background is different from his/her
own (age, race, gender, class, region, culture,
religion, family composition etc.)
1
2
3
4
5
6
7
N/A
v. Helping you network effectively
1
2
3
4
5
6
7
N/A
w. Helping you set career goals
1
2
3
4
5
6
7
N/A
x. Helping you balance work with your
personal life
1
2
3
4
5
6
7
N/A
y. Understanding his/her impact as a role
model for you
1
2
3
4
5
6
7
N/A
z. Helping you acquire resources
1
2
3
4
5
6
7
N/A
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OMB #0925-XXXX
EXP. XX/XXXX
13. Please respond to the following statements about your primary mentor.
My mentor
did not do
this
My mentor
tried to do
this but was
ineffective
My mentor
did this
sometimes
and was
effective
My mentor
did this
frequently,
and was
effective
a. My mentor gave me an overview of
how my research fit into an overall
research project.
1
2
3
4
b. My mentor helped me develop my
research skills.
1
2
3
4
c. My mentor showed interest in my
research project.
1
2
3
4
d. My mentor was available to me when I
had problems or questions about my
research.
1
2
3
4
e. My mentor offered constructive
feedback when necessary.
1
2
3
4
f. My mentor and I developed a
relationship based on trust.
1
2
3
4
g. My mentor understood how I learn
best.
1
2
3
4
h. My mentor created an environment that
allowed me to achieve my goals.
1
2
3
4
i. My mentor seemed so busy that I was
afraid to interrupt her/him.
1
2
3
4
j. My mentor had an effective mentoring
style.
1
2
3
4
k. My mentor acted as a positive role
model.
1
2
3
4
l. My mentor showed interest in me as a
person.
1
2
3
4
m. My mentor fostered my independence.
1
2
3
4
n. My mentor fostered confidence in my
skills.
1
2
3
4
o. My mentor appreciated my
contributions.
1
2
3
4
p. My mentor encouraged me to be
creative.
1
2
3
4
q. My mentor made me enthusiastic about
my project.
1
2
3
4
OMB #0925-XXXX
EXP. XX/XXXX
r. My mentor helped me feel curious
about my project.
1
2
3
4
s. My mentor treated me as a colleague.
1
2
3
4
t. My mentor helped me decide on a
career path.
1
2
3
4
u. My mentor communicated his/her
expectations of me.
1
2
3
4
v. My mentor respected my goals.
1
2
3
4
w. My mentor allowed me to take
ownership in my research.
1
2
3
4
x. My mentor created an environment
where I felt safe to make mistakes.
1
2
3
4
y. My mentor made me feel included in
the lab.
1
2
3
4
z. My mentor regularly assessed skills
and knowledge that I gained in the lab.
1
2
3
4
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OMB #0925-XXXX
EXP. XX/XXXX
14. In your mentoring relationship, how important is it to you that your primary mentor does
the following:
Not Important
Somewhat
Important
Very Important
a. Is willing to discuss diversity
1
2
3
b. Considers their own cultural
background, as well as yours
1
2
3
c. Values and respects cultural
differences
1
2
3
15. In your mentoring relationship, how skilled is your primary mentor in the following:
Not Skilled
Somewhat
Skilled
Very Skilled
a. Discussing diversity
1
2
3
b. Considers their own cultural
background, as well as yours
1
2
3
c. Values and respects cultural
differences
1
2
3
16a. How would you rate the overall quality of the mentoring you received from your primary
mentor?
Very Low
1
Average
2
3
4
Very High
5
6
7
16b. How satisfied are you with the mentoring you are receiving from your primary mentor?
Very Low
1
Average
2
3
4
Very High
5
6
7
17. To what extent do you feel your primary mentor is meeting your expectations?
Very Low
1
Average
2
3
4
Very High
5
6
7
OMB #0925-XXXX
EXP. XX/XXXX
18. Do you have someone at a similar educational level as you (i.e. a peer) who you consider
an academic/career mentor?
No
Yes
a. How many different peer mentors do you have? _________
b. Which of the following do your peer mentors help you with? (Choose all that apply)
Research issues
Social and emotional needs (e.g. sharing concerns about school)
Tangible help (e.g. advice about faculty and classes, help with writing)
Networking assistance (e.g. helping you meet other people in your field)
Career planning (e.g. giving advice, helping find opportunities)
Other (specify): ________________________________
c. How do you usually communicate with your primary peer mentor?
In-person
Phone/Skype
Email/Text
Other (specify): ______________
d. How often do you usually communicate with your primary peer mentor?
Weekly
Montly
Several times a year
Annually or less
e. How did you find this mentor?
Through your local campus name for BUILD
They were assigned in some other way by your department or campus
You were matched through the National Research Mentoring Network (NRMN)
Matched through some other formal program
OMB #0925-XXXX
EXP. XX/XXXX
You sought out your mentor independently
Other (specify): ______________
19. Do you have anyone who you currently mentor about academic issues who is junior to you?
No
Yes
a. How many different people to your regularly mentor currently? ______
b. At what education level are the people you mentor? (Choose all that apply)
College students
High school students
Middle or elementary school students
c. Which of the following do help your mentees with? (Choose all that apply)
Research issues
Social and emotional needs (e.g. sharing concerns about school)
Tangible help (e.g. advise about faculty and classes, help with writing)
Networking assistance (e.g. helping you meet other people in your field)
Career planning (e.g. giving advice, helping find opportunities)
Other (specify): ___________________________
d. How do you communicate with your mentees?
In-person
Phone/Skype
Email/Text
Other (specify): ______________
OMB #0925-XXXX
EXP. XX/XXXX
e. On average, how often do you usually communicate with your mentees?
Weekly or more often
Monthly
Several times a year
Annually or less
f. How did you first connect with your mentees? (Choose all that apply)
Through local campus program for BUILD
They were assigned in some other way by your department or campus
You were matched through the National Research Mentoring Network) (NRMN)
Matched through some other formal program
They sought you out independently
Other (specify): _________________
Back
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Cancel
OMB #0925-XXXX
EXP. XX/XXXX
20. Please rate how skilled you feel you are in each of the following areas when mentoring
those junior to you:
Not at all
Extremely
a. Active listening
1
2
3
4
5
6
7
N/A
b. Providing constructive feedback
1
2
3
4
5
6
7
N/A
c. Establishing a relationship based on trust
1
2
3
4
5
6
7
N/A
d. Identifying and accommodating different
communication styles
1
2
3
4
5
6
7
N/A
e. Employing strategies to improve communication with
mentees
1
2
3
4
5
6
7
N/A
f. Coordinating effectively with your mentees’ other
mentors
1
2
3
4
5
6
7
N/A
g. Working with mentees to set clear expectations of
the mentoring relationship
1
2
3
4
5
6
7
N/A
h. Aligning your expectations with your mentees’
1
2
3
4
5
6
7
N/A
i. Considering how personal and professional
differences may impact expectations
1
2
3
4
5
6
7
N/A
j.Working with mentees to set research goals
1
2
3
4
5
6
7
N/A
k. Helping mentees develop strategies to meet goals
1
2
3
4
5
6
7
N/A
l. Accurately estimating your mentees’ level of
scientific knowledge
1
2
3
4
5
6
7
N/A
m. Accurately estimating your mentees’ ability to
conduct research
1
2
3
4
5
6
7
N/A
n. Employing strategies to enhance your mentees’
knowledge and abilities
1
2
3
4
5
6
7
N/A
o. Motivating your mentees’
1
2
3
4
5
6
7
N/A
p. Building mentees’ confidence
1
2
3
4
5
6
7
N/A
q. Stimulating your mentees’ creativity
1
2
3
4
5
6
7
N/A
r. Acknowledging your mentees’ professional
contributions
1
2
3
4
5
6
7
N/A
s. Negotiating a path to professional independence
with your mentees
1
2
3
4
5
6
7
N/A
t. Taking into account the biases and prejudices you
bring to the mentor/mentee relationship
1
2
3
4
5
6
7
N/A
u. Working effectively with mentees whose personal
background is different from your own (age, race,
gender, class, region, culture, religion, family
composition etc.)
1
2
3
4
5
6
7
N/A
v. Helping your mentees network effectively
1
2
3
4
5
6
7
N/A
w. Helping your mentees set career goals
1
2
3
4
5
6
7
N/A
OMB #0925-XXXX
EXP. XX/XXXX
x. Helping your mentees balance work with their
personal life
1
2
3
4
5
6
7
N/A
y. Understanding your impact as a role model before
your research experience
1
2
3
4
5
6
7
N/A
z. Helping your mentees acquire resources
1
2
3
4
5
6
7
N/A
OMB #0925-XXXX
EXP. XX/XXXX
21. In your mentoring relationship, how important is it to you that YOU do the following:
Not Important
Somewhat
Important
Very Important
a. Be willing to discuss diversity issues
1
2
3
b. Consider their own cultural
background and your own
1
2
3
c. Value and respect cultural
differences
1
2
3
22. In your mentoring relationship, how skilled are YOU in the following:
Not Skilled
Somewhat
Skilled
Very Skilled
a. Discussing diversity
1
2
3
b. Considering their own cultural
background, as well as yours
1
2
3
c. Valuing and respecting cultural
differences
1
2
3
22d. How satisfied are you with the mentoring you are providing to your mentees?
Very Low
1
Average
2
3
4
Very High
5
6
7
23. Do you have anyone who you currently mentor on academic/career issues who is at a
similar level to yours (a peer)?
No
Yes
a. How many different people do your regularly mentor currently? ______
b. Which of the following do help your mentees with? (Choose all that apply)
Research issues
Social and emotional needs (e.g. sharing concerns about school)
Tangible help (e.g. advise about faculty and classes, help with writing)
OMB #0925-XXXX
EXP. XX/XXXX
Networking assistance (e.g. helping you meet other people in your field)
Career planning (e.g. giving advice, helping find opportunities)
Other (specify): ___________________________
c. How do usually communicate with your peer mentees?
In-person
Phone/Skype
Email/Text
Other (specify): ______________
d. On average, how often do you usually communicate with your peer mentees?
Weekly or more often
Monthly
Several times a year
Annually or less
e. How did you first connect with your mentees? (Choose all that apply)
Through local campus program for BUILD
They were assigned in some other way by your department or campus
You were matched through the National Research Mentoring Network (NRMN)
Matched through some other formal program
They sought you out independently
Other (specify): _________________
OMB #0925-XXXX
EXP. XX/XXXX
C. Research and Grants
24.Have you had any opportunity to conduct your own scientific research or to participate in
scientific research directed by others in the past year?
No
Yes
25. Please check all research activities you participated in last year (Choose all that apply)
Hands-on research activities with laboratory equipment in a class
-Worked in a laboratory in a college/university
-Worked on research in a non-academic location
-Designed your own research experience
-Conducted research that had an unknown outcome
-Contributed to research that advanced knowledge (even if it was a very small advancement)
-None of the above
26.
Since you started college, have you applied for or received funding to support your own
research? Please do not include fellowships or scholarships that primarily pay for tuition,
fees, or living expenses. Also, please do not include service projects unless they include a
research component.
No
Yes
OMB #0925-XXXX
EXP. XX/XXXX
Below is a list of all research funding support you have provided to us in the past.
Have you applied for any additional funding to support your own research that is not on the
list (either as the lead investigator, with a faculty advisor as the lead, or for a other paid
position) OR has the status of previous submissions changed?
No
Yes
27.Please complete or update information for each grant or proposal:
a. Funding Agency Type:
Your university
Federal agency (e.g. NIH, NSF)
Nonfederal governmental
Nonprofit (e.g. foundations)
For-profit
Other (specify): ____________
b. [If NIH or Other Federal] Full grant number if available
c. Agency/Foundation/Company Name: __________________
d. Role:
Principal Investigator
Co-Principal Investigator
Investigator
Other (specify): _____________
OMB #0925-XXXX
EXP. XX/XXXX
e. Submission status:
Submitted
Re-submitted with revisions
Not funded
NIH Impact score (if applicable): ______
Funded
NIH Impact score (if applicable): ______
f. Project Title: __________________
g. Amount (total across all years):
Less than $50,000
$50,000-$99,999
$100,000-$249,999
$250,000-$499,999
$500,000 or more
h. Start Date (e.g., 07/08/2015)
i. End Date (e.g., 07/08/2016)
j. What was the main purpose of the funding?
Research
Training of others (e.g., students, peers, workforce)
Your career development
Other (specify): _____________________
OMB #0925-XXXX
EXP. XX/XXXX
28. Have you conducted research that is not funded by the grants listed above?
No
Yes
a. What type of research was this?
Literature review, synthesis of existing knowledge, and/or conceptual
Analysis of existing (secondary) data
Analysis of data you collect (primary analysis)
b. What was the research for?
A class or degree requirement
Part of a paid job (e.g. research assistant), internship, or training program
Related to your role as an independent researcher
c. What was your role?
Project Lead on my own project
Working on someone else’s student-led project
Working on a faculty member-led project
Other (Specify): __________________________________
OMB #0925-XXXX
EXP. XX/XXXX
29. Do you have any peer-reviewed publications accepted, in-press, or published in the past year?
No
Yes
Below is a list of publications you have provided to us in the past.
Do you have any peer-reviewed publications that you have had accepted to add to this list?
No
Yes
If yes, please answer the following questions:
a. PMID #: ________________
b. List allAuthors (Last FM, comma separated): ______, ______, ______, ______
c. Title: __________________
d. Journal Name: __________________
e. Year Published (or indicate “in press” or “epub ahead”): ________
f. Volume: ______
g. Issue: ______
h. Page Numbers: ______
i. DOI or URL for epubs: ____________________
OMB #0925-XXXX
EXP. XX/XXXX
30. Are there other scientific publications (e.g. book chapters, books, reports, non-peer
reviewed journal articles, working papers, other) to add to this list?
No
Yes
a. Publication Type:
Chapter
Book
Other, specify: ____________
b. List all Authors (Last FM, comma separated): ______, ______, ______, ______
Complete the applicable information below depending on publication type:
c. Book/Anthology Title: __________________
d. Chapter Title : __________________
e. [If Chapter] Editors: __________________
f. Year Published: ______
g. Edition: ______
h. Publisher: ________________
i. City: ________________
j. State: __________
k. [If Book or Chapter] Page Numbers: ______
l. DOI or URL for epubs: ____________________
31. Have you presented at a scientific conference in the last year (including posters)?
No
Yes
OMB #0925-XXXX
EXP. XX/XXXX
32. Have you ever participated in technology transfer activities (including issued patents,
completed licenses, and drug, device, or diagnostic approvals)?
No
Yes
Below is a list of technology transfer activities (including issued patents, completed licenses,
and drug, device, or diagnostic approvals you have provided to us in the past.
Please review the list. Are there any to add to this list?
No
Yes
a. Please enter a title and brief description for each Technology Activity:
New patent issued
License completed
Drug, device, or diagnostic received regulatory approval
Result of basic research commercialized
Other (specify): _____________________
b. Please provide a brief description:
OMB #0925-XXXX
EXP. XX/XXXX
33. Have you received any honors or awards in the past year?
No
Yes
If yes, please provide the name/ title of the honors or awards you’ve received:
________________________________________________________________
________________________________________________________________
34. Have you held office in any pre-professional or profession organization in the past year?
No
Yes
If yes, please list any offices you have held in pre-professional or professional organizations in
the past year:
________________________________________________________________
35. Have you provided service to any federal agencies (e.g. reviewer for NIH/NSF/CDC or
similar proposals, member of federal agency advisory council, etc.) in the past year?
No
Yes
If yes, please list any service to federal agencies you have performed in the past year:
_________________________________________________________________
_________________________________________________________________
36. Have you provided service to any non-federal agencies such as state agencies or
foundations in the past year?
No
Yes
If yes, please list any service to non-federal agencies you have performed in the past year:
______________________________________________________________________
OMB #0925-XXXX
EXP. XX/XXXX
D. Student Psychological Outcomes
37. Indicate the importance to you personally of each of the following:
Essential
Very
Important
Somewhat
Important
Not
Important
a. Obtaining recognition from
colleagues for contributions to
my special field.
1
2
3
4
b. Making a theoretical
contribution to science.
1
2
3
4
c. Becoming an authority in my
field.
1
2
3
4
38. Indicate to what extent the following statements are true of you:
Strongly
Disagree
Disagree Neutral
Agree
Strongly
Agree
a. I have a strong sense of belonging to
the community of scientists
1
2
3
4
5
b. I derive great personal satisfaction
from working on a team that is doing
important research
1
2
3
4
5
c. I have come to think of myself as a
‘scientist’
1
2
3
4
5
d. I feel like I belong in the field of
science
1
2
3
4
5
OMB #0925-XXXX
EXP. XX/XXXX
39. Indicate to what extent you are confident that you can complete the following tasks:
Not at all
confident
A little
confident
Somewhat
Confident
Very
Confident
Absolutely
Confident
a. Use technical science skills (use of
tools, instruments, and/or
techniques)
1
2
3
4
5
b. Generate a research question to
answer
1
2
3
4
5
c. Figure out what data/observations
to collect and how to collect them
1
2
3
4
5
d. Create explanations for the result
of the study
1
2
3
4
5
e. Use scientific literature and/or
reports to guide research
1
2
3
4
5
1
2
3
4
5
f.
Develop theories (integrate and
coordinate results from multiple
studies)
40. Rate yourself on each of the following traits as compared with the average person your
age. We want the most accurate estimate of how you see yourself. (Mark one in each row)
Highest
10%
Above
Average
Academic ability
Drive to achieve
Mathematical ability
Self-confidence
(intellectual)
41. Will you pursue a science-related research career?
Definitely yes
Possibly yes
Uncertain
Possibly no
Definitely no
Average
Below
Average
Lowest
10%
OMB #0925-XXXX
EXP. XX/XXXX
42. Since we last contacted you, have you participated in any training to improve your skills
as a mentor or as a mentee?
No
Yes
a. Type of training (Select all that apply)
In-person
On-line that occurs in scheduled, real-time (synchronous)
On-line or other virtual that you can take at any time that provides feedback or interaction
with others (asynchronous
Self-study (by any means, but no interaction or feedback)
b. Approximately how many hours was your training over the past year?
_____hours
43. Have you completed formal training/workshops related to your career or research
(minimum of at least 4 hours duration)?
No
Yes
If yes, please indicate the focus of the training:
Back
Next
Cancel
OMB #0925-XXXX
EXP. XX/XXXX
Yes
No
a. On NIH funding?
b. On other funding?
c. On biomedical career development (e.g., training in
leadership, teaching, mentoring, publishing, gaining tenure,
etc.)?
d. On other biomedical research related topics?
45. Please indicate “Yes” or “No” for each of the following:
Yes
a. Are you deaf or do you have serious difficulty hearing?
b. Are you blind or do you have serious difficulty seeing, even when
wearing glasses?
c. Because of a physical, mental, or emotional condition, do you have
serious difficulty concentrating, remembering, or making decisions?
d. Do you have serious difficulty walking or climbing stairs?
e. Do you have difficulty dressing or bathing?
f. Because of a physical, mental, or emotional condition, do you have
difficulty doing errands alone such as visiting a doctor’s office or
shopping?
No
OMB #0925-XXXX
EXP. XX/XXXX
46. Are you Hispanic, Latino/a, or Spanish Origin?
No
Yes
47. What is your race? Check all that apply
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
| File Type | application/pdf |
| File Modified | 2016-06-02 |
| File Created | 2016-01-11 |