Form 1 Attachment 2 Physician Surveys

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National Institutes of Health
Graduate Medical Education

Subject:
Evaluator:
Site:
Period:
Dates of Activity:
Activity:
Alumni Survey
Year Later
Form:
Alumni Self Evaluation 1 Year Later

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Graduate Medical Education Alumni Survey
(OMB # 0925-0602; expires 3/31/2016)
Please take a few minutes to complete the survey below, which will ask about your current work experience
and other accomplishments. It will also invite you to retrospectively evaluate your training program and serve,
if you are agreeable, to be a resource or advisor to current and future trainees in your program.
Through this survey, the
Graduate Medical Education Program is collaborating with your program to (a)
identify opportunities that will enhance the clinical research training we provide our residents and fellows and
(b) stay better connected with you and the other graduates of our clinical training programs.
Please note that the information you share with us will only be accessible to authorized GME staff. When
reported external to the GME office as part of our quality improvement process, all feedback will be
anonymous and reported in the aggregate.
Thank you for helping us to improve and stay connected.
**lf you are accessing this survey at the NIH or another Federal institution, Network restrictions may prevent
you from copying and pasting text directly from Office documents into this survey via Microsoft Internet
Explorer. Please use Google Chrome or Mozilla Firefox as alternatives to enable copy and paste functions.
Burden Disclosure Statement: Public reporting burden for this collection of information is estimated to
average 20 minutes per survey, 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¬
0602). Do not return the completed form to this address.
To review the NIH/E*Value Privacy Act Notification Statement, please click here
Section 1 of 5: General Information

Are you using a different name than the one you used during training (stated at the top of this
survey)?
(Question 1 of 38 -

Selection] Option
|No
you are using a different name than the one you used during training, please state the name you
are currently using.
(Question 2 of 38)

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Preferred e-mail address

(Question 3 of 38 -

Alternate e-mail address

(Question 4 of 38)

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(Question

38)

In w h i c h of the A C G M E - a c c r e d i t e d training p r o g r a m s b e l o w
did y o u train, if a p p l i c a b l e ?
Program - Institution

Selection

Year

Option
{Select}
Allergy and Immunology Anatomic Pathology - NCI
Critical Care - CC
Cytopathology - NCI
Endocrinology and Metabolism Hematology Hematopathology - NCI
Hospice & Palliative Care - CC/ODDCC
Infectious Diseases - NIAID
Medical Biochemical Genetics Medical Genetics - NHGRI
Medical Oncology - NCI
Pediatric Endocrinology Psychiatry - NIMH
Rheumatology Surgical Neurology Transfusion Medicine/Blood Banking - CC
Vascular Neurology - NINDS

Selection

Option
{Select}
Allergy and Immunology - NIAID
Anatomic Pathology - NCI
Critical Care - CC
Cytopathology - NCI
Endocrinology and Metabolism - NIDDK
Hematology - NHLBI
Hematopathology - NCI
Hospice & Palliative Care - CC/ODDCC
Infectious Diseases - NIAID
Medical Biochemical Genetics - NHGRI .
Medical Genetics - NHGRI
Medical Oncology - NCI
Pediatric Endocrinology - NICHD
Psychiatry Rheumatology Surgical Neurology - NINDS
Transfusion Medicine/Blood Banking - CC
Vascular Neurology - NINDS

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(Question

6 of

If y o u didn't train in a n A C G M E - a c c r e d i t e d training p r o g r a m ,
w h i c h of the other c l i n i c a l a n d t r a n s i a t i o n a i p r o g r a m s did y o u a t t e n d ?
Program - Institution

Selection

Year

Option
{Select}
- NCI
Pediatric Oncology - NCI
Radiation Oncology - NCI
Surgical Oncology - NCI
Oncology - NCI
Cardiac/Cardiovascular Imaging - NHLBI
Reproductive Endocrinology - NICHD
Gastroenterology - NIDDK
- NIDDK
Human Motor Control - NINDS
Program not listed, see below

Option
[{Select}
| Neuro-Oncology - NCI
| Pediatric Oncology - NCI
| Radiation Oncology - NCI
|Surgical Oncology - NCI
| Urologic Oncology - NCI
| Cardiac/Cardiovascular Imaging - NHLBI
| Reproductive Endocrinology - NICHD
Gastroenterology - NIDDK
NIDDK
[Human Motor Control - NINDS
|Program not listed, see below

If the clinical and transiationai training program you attended is not listed above, please let us know
its name:

(Question 7 of 38 )

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Which
(Question

sponsored the clinical or transiationai program

was not listed.

of 38)

(Question 9 of 38)
What professional degrees do you hold?
MD. Area(s) of specialty:
PhD. Area(s) of specialty:
JD. Area(s) of specialty:
Master's. Area(s) of specialty:
Other:

Please list your ABMS (Board) certification(s):

(Question 10 of 38 -

Section 2 of 5: Work Experience

Name of your current employer/institution

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(Question

of 38 -

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Employer/institution type

Selection

(Question 12 of 38 -

Option
Academic
NIH
Government regulatory agency
Pharmaceutical
Other research
Private practice
Other
Notes

If y o u selected

(Question 13 of

please explain.

What is your current academic status/title?

Selection

Mandatory)

(Question 14 of 38)

Option
Dean
Chair
Non-academic
Associate Professor
Professor
Instructor
Assistant Professor

Academic Status/Title: Notes

(Question

If y o u selected 'Other,' please explain.

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Is your current academic appointment a tenure track position?

(Question

of 38)

Option
Yes
No'
[Not applicable (do

have an academic appointment)

If your current academic appointment is a tenure track position, do you currently have tenure?
(Question
of 38)

Selection

Option
Yes
No, not yet eligible
No

Are you currently performing clinical and/or transiationai research?

(Question 18 of

|Yes
No

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(Question

of 38)

What are your current
funding s o u r c e s ?

What is the dollar amount of your grant(s)?

ALL FIELDS REQUIRE
RESPONSE

None

Less
than
$50K

$100K

$250K

to
$500K

to$1M

K01 Mentored Research
Scientist Development
K08 Mentored Clinical
Scientist Development
Mentored Clinical
Scientist Development
K22 Career Transition Award
K23 Mentored Patient
Oriented Research
K24 Midcareer Investigator
Award in Patient Oriented
Research
K30 Clinical Research
Curriculum Award
K99/R00 Pathway to
Independence Award
R01 Research Project Grant
Program
R03 Small Group Program
R21 Exploratory
Developmental Research
Award
Intramural NIH Research
Other Federal Funding
Private
University
Pharmaceutical
Other

Funding Sources: Notes

(Question 20 of

If y o u selected 'other federal

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'private funding,'

f u n d i n g , ' please explain.

Greater
than $1M

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What are the most important clinical research challenges facing you in your career currently?
(Optional)
(Question 21 of 38 )

(Question 22 of 38 - Mandatory )
What is your professional title?
What organization and/or department do you work for?
What are your clinical and/or research interests?
Address Line 1
Address Line 2 (optional)
City/Town
State
Zip Code
Country
Phone Number

(Question 23 of 38 )
What proportion of
time is devoted to the following:
Direct patient care (
%):
Research (

%):

Teaching (.
Administration (

%):

Total %:

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Please note any professional honors or awards you have received.

(Question 24 of

Feel free to copy and paste f r o m your r e s u m e or other d o c u m e n t .
**lf you are accessing this survey at t h e N I H or another Federal institution, N e t w o r k restrictions
m a y prevent you from copying and pasting text directly f r o m Office d o c u m e n t s into this survey via
Microsoft Internet Explorer. Please use G o o g l e C h r o m e or Mozilla Firefox as alternatives to enable
copy and paste functions.

Section 3 of 5: Publications

If you have been published since completing your training program, please share with us the number
of peer-reviewed publications which list you as the first or second author.
(Question 25 of 38 )

Selection Option
1-3
4-6
7-10
11-15
16-20
21-25
>25
None
If you would
document.

please list your publications. Feel free to copy and paste from your resume or other
(Question 26 of 38 - Mandatory )

**lf you are accessing this survey at t h e N I H or a n o t h e r Federal institution, N e t w o r k restrictions
m a y prevent you from copying and pasting text directly f r o m Office d o c u m e n t s into this survey via
Microsoft Internet Explorer. Please use G o o g l e C h r o m e or Mozilla Firefox as alternatives to e n a b l e
copy and paste functions.

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Section 4 of 5: Training Experience

What is the overall degree of impact your NIH training program has had on your professional career?
(Question
38 )

N/A
[

0

(Question

No
|

Little Impact
1

|

2

Some Impact

Much Impact

3

4

|

Considerable
Impact
|

5

28 of 38 - Mandatory )

What degree of impact did your training
program nave on your
to.

No
Impact

Little

Some

Much
Impact

Considerable
Impact

Successfully complete your Board Exam(s)

A

2.0

3.0

4.0

5.0

Perform typical procedures for specialty

1,0

2.0

3.0

4.0

5.0

Perform successfully in an academic or research setting

1.0

2.0

3.0

4.0

5.0

Perform successfully in a non-academic or non-research
setting

1.0

2.0

3.0

4.0

5.0

Teach (medical students, residents, fellows, and/or patients)

1.0

2.0

3.0

4.0

5.0

Compete successfully for grants

1.0

2.0

3.0

4.0

5.0

Compete successfully for desired professional opportunities

1.0

2.0

3.0

4.0

5.0

Work well with other members of a healthcare team

1.0

2.0

3.0

4.0

5.0

Manage and lead others

1.0

2.0

3.0

4.0

5.0

Stay current in specialty

1.0

2.0

3.0

4.0

5.0

Network with other key individuals in field

1.0

2.0

3.0

4.0

5.0

Achieve work-life balance

1.0

2.0

3.0

4.0

5.0

Become a life-long learner

1.0

2.0

3.0

4.0

5.0

Be knowledgeable of established and evolving biomedical,
clinical, epidemiological and social-behavioralsciences, when
applying this knowledge to patient care (Medical Knowledge)

1.0

2.0

3.0

4.0

5.0

Provide patient care that is compassionate, appropriate, and
effective for the treatment of health problems and the promotion
of health (Patient Care)

1.0

2.0

3.0

4.0

5.0

Effectively exchange information and collaborate with patients,
their families, and health professionals (Interpersonal &
Communication Skills)

1.0

2.0

3.0

4.0

5.0

Carry out professional responsibilities and demonstrate an
adherence to ethical principles (Professionalism & Ethics)

1.0

2.0

3.0

4.0

5.0

Investigate and evaluate one's care to patients, to appraise and
assimilate scientific evidence, and to continuously improve
patient care based on constant self-evaluation and life-long
learning (Practice-based Learning and Improvement)

1.0

2.0

3.0

4.0

5.0

Be aware of and responsive to the larger context and system of
healthcare, as well as the ability to
effectively on other
resources in the system to provide optimal healthcare (Systems
-based Practice)

1.0

2.0

3.0

4.0

5.0

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Were you able to find and begin employment (or additional training) of your choice within your
specialty/subspecialty upon completing your GME training at NIH?
(Question 29 of 38 )

Selection Option
No
Employment/Additional Training: Notes
If

(Question 30 of 38 )

please explain.

What were the best parts of your GME training at NIH?

(Question 31 of 38 )

What w a s missing from or could be improved about your training program?

(Question 32 of

If you could start your GME training again from the beginning, would you choose NIH for some or all
of this training?
(Question 33 of 38 )

Selection Option
Yes
Unlikely
Maybe

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GME Program Selection: Notes

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(Question 34 of 38 )

If 'Unlikely' please explain.

How likely are you to recommend NIH for GME training to prospective research-oriented applicants?
(Question 35 of 38 - Mandatory )
Unlikely

Somewhat Likely

Likely

2

3

Likelihood to Recommend NIH GME training: Notes

(Question 36 of

please explain.

Please provide any additional comments about GME or research training at NiH. (optional)
(Question 37 of 38 )

Section 5 of 5: Alumni Network

Would you be willing to serve a s a resource for current NIH GME trainees who seek to learn from
your professional experiences?
(Question 38 of 38 - Mandatory)

|Yes
No

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NIH-Duke Master’s Program in Clinical
Research

OMB #0925-0602; expires 3/31/2016

Mentor
Tutor

Project Title
Secondary Project Title