Form 2 Attachment 1 Physician and Student Surveys

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

OMB #0925-0602 Expires 3/31/2016

OMB #0925-0602 Expires 3/31/2016

National Institutes of Health
Graduate Medical Education
Subject:
Evaluator:
Site:
Period:
Dates of Activity:
Activity:

Clinical Electives Program Alumni 1 Year Later - LCME

Form:

Clinical Electives Program Alumni Survey

Clinical Electives Program Alumni Survey (OMB # 0925-0602; expires 3/30/2016)
Please take a few minutes to complete the survey below, which will ask about your current
professional experiences 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 NIH Office of Clinical Research Training and Medical Education
(OCRTME) is collaborating with your program to (a) identify opportunities that will enhance the
clinical research training we provide 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 OCRTME
staff. When reported external to the 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.
**If 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
Are you using a different name than the one you used during training (stated at the top of this
survey)? (Question 1 of 19 )

Selection Option
Yes
No
If you are using a different name than the one you used during training, please state the name you are
currently using. (Question 2 of 19 )

Preferred e-mail address (Question 3 of 19 )

Alternate e-mail address (Question 4 of 19 )

If you participated in a clinical elective(s), please select the appropriate clinical elective(s). Please
check all that apply. If you completed a research tutorial, please mark 'I participated in a research
tutorial, not a clinical elective.' (Question 5 of 19 - Mandatory )

Selection

Option
Addiction Medicine
Alcoholism
Cardiology
Clinical Pharmacology and Therapeutics for Senior Medical Students
Critical Care Medicine
Endocrinology and Metabolism
Gynecology Consult Service
Health Services
Hematology
Hepatology
I participated in a research tutorial, not a clinical elective.
Infectious Diseases
Interdisciplinary Women's Health
Internal Medicine Consult Service
Medical Genetics
Medical Informatics
Medical Oncology
Neurology/Neuroscience Research
Neurosurgery
Nuclear Medicine
Otolaryngology—Head and Neck Surgery
Pain and Palliative Care
Pathology
Pediatric Consult Service
Pediatric Endocrinology

Pediatric Oncology
Pediatric Psychopharmacology
Psychiatry/Psychopharmacology
Psychiatry/Psychosomatic Medicine
Radiation Oncology
Rehabilitation Medicine
Rheumatology
Sickle Cell Anemia
Surgical Oncology
Surgical Thoracic & GI Oncology
Transfusion Medicine
Urologic Oncology
If you participated in a research tutorial, please let us know the name of your research preceptor and
Institute or Center. (Question 6 of 19 )

What professional degrees do you hold? Please check all that apply. (Question 7 of 19 - Mandatory )

Selection Option
MD
MD/PhD
DO
DDS
Other
If you selected “Other” for “What professional degrees do you hold,” please specify. (Question 8 of 19
)

(Question 9 of 19 - Mandatory )
What is your current training
status?

Institution

Specialty
(if applicable)

Residency
Fellowship
What is your current professional status? (Question 10 of 19 - Mandatory )

Selection

Option
PGY-1 Trainee
PGY-2 Trainee
Other Government Agency
Pharmaceutical Industry
Other research
Other

If you selected “Other” for “What is your current professional status, please specify. (Question 11 of 19
)

Are you currently performing clinical and/or translational research? (Question 12 of 19 - Mandatory )

Selection Option
Yes
No
(Question 13 of 19 - Mandatory )
What degree of impact did your clinical
elective or research tutorial at NIH have
on your:

No
Impact

Little
Impact

Some
Impact

Much
Impact

Considerable
Impact

Obtaining a residency or fellowship
position through the Match

1.0

2.0

3.0

4.0

5.0

Clarifying academic goals

1.0

2.0

3.0

4.0

5.0

Clarifying professional goals

1.0

2.0

3.0

4.0

5.0

Performing successfully in an academic or
research setting

1.0

2.0

3.0

4.0

5.0

Competing successfully for desired
professional or academic opportunities

1.0

2.0

3.0

4.0

5.0

Networking with key individuals in field

1.0

2.0

3.0

4.0

5.0

Desire to pursue residency/fellowship
training at the NIH

1.0

2.0

3.0

4.0

5.0

No
Impact

Little
Impact

Some
Impact

Much
Impact

Considerable
Impact

1.0

2.0

3.0

4.0

5.0

(Question 14 of 19 - Mandatory )

Because of your clinical elective or
research tutorial, how likely are you to
pursue your interest in clinical research?
(Question 15 of 19 - Mandatory )

How likely are you to recommend NIH's Clinical Electives Program
to prospective clinical research-oriented applicants?

Unlikely

Somewhat
Likely

Likely

1.0

2.0

3.0

What were the best parts of your clinical elective or research tutorial at the NIH? (Question 16 of 19 )

What was missing from or could have improved your clinical elective or research tutorial? (Question 17
of 19 )

If you could start your clinical elective or research tutorial again from the beginning, would you choose
the NIH? (Question 18 of 19 - Mandatory )

Selection Option
Yes
No
Please provide any additional comments about the NIH Clinical Electives Program. (Question 19 of 19 )