Download:
pdf |
pdfOMB #0925-XXXX
EXP. XX/XXXX
Attachment 14:
BUILD Faculty Annual Follow-up Survey
OMB #0925-XXXX
EXP. XX/XXXX
BUILD Faculty Annual Tracking Survey
Your institution 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 can benefit students interested in these
careers.
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.
Your institution 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 or because you completed the 2016 Faculty survey. All of the
information you provide will remain protected and secured to the extent permitted
by law.
Through this survey, we will gain understanding of faculty activities, including
teaching practices, research, scholarly productivity, and mentoring.
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.
Back
Next
Cancel
OMB #0925-XXXX
EXP. XX/XXXX
Thank you for responding to this information request. We would first like to get
some information about your recent professional activities.
1. In the past five years, have you been the Principal Investigator of an NIHfunded research grant?
No
Yes
2. In the past five years, have you been the Principal Investigator of any
other extramural (other government, foundation, corporate, or other)
research grants?
No
Yes
3. In the past five years, how many peer-reviewed journal articles have you
published?
0
1
2–5
6 or more
4. In the past five years, have you presented at a scientific conference
(including posters)?
No
Yes
5. Has your research ever been the subject of technology transfer activities
(including issued patents, completed licenses, and drug, device, or
diagnostic approvals)?
No
Yes
Back
Next
Cancel
OMB #0925-XXXX
EXP. XX/XXXX
A. Faculty Rank and Position
We would like to be sure our information is current about your position.
6. Last year, you told us you were ______ position at ______ institution. Has
that changed?
No
Yes
7. What is your current primary position? (Please indicate all that apply)
In school
Working (including internships and significant volunteer positions)
Retired
Unemployed, looking for work
Otherwise not in labor force
Other (specify): _________________
a. Expected completion date (year): _____
Expected degree: _____
b. Status:
Full Time
Part Time
c. Institution: _________________
d. Major: _________________
OMB #0925-XXXX
EXP. XX/XXXX
e. Paid Employment (check all that apply):
Full Time
Part Time
Internship or student placement
Seasonal (full-time or part-time)
No paid employment
Position: _________________
Institution or Company: _________________
f. Is this paid position related to research?
No
Yes
g. Is this new job/position considered a promotion or advancement?
No
Yes
h. Volunteer
Position: _________________
Institution or Company: _________________
No volunteer position
i. Is this volunteer position related to research?
No
Yes
OMB #0925-XXXX
EXP. XX/XXXX
8. 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
9. During the past year, did you apply to any degree or certificate program?
Note: If you completed a program above, please indicate here any other
program applications.
No
Yes
If yes, please indicate the following:
a. Degree / certificate the program awards: _________________
b. Major / area of study: _________________
c. From which institution or school: _________________
d. Date applied: MM / YR
e. Status of application:
Accepted and will attend
Accepted and will not attend
Waitlisted
Pending
Not accepted
OMB #0925-XXXX
EXP. XX/XXXX
10. Please attach your most recent academic vita (such as a CV).
Upload
11. 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
12. What type of courses do you primarily teach? (Mark one)
Undergraduate courses
Graduate courses
Non-credit courses
I do not teach
13. In the past year, have you taught a graduate course?
No
Yes
OMB #0925-XXXX
EXP. XX/XXXX
14. During the past year, have you taken advantage of any of the following
professional development opportunities at this institution? (choose all that
apply)
Paid workshops focused on teaching
Paid workshops focused on mentoring
Paid workshops focused on conducting research
Paid sabbatical leave
Travel funds paid by the institution
Travel funds paid by a grant (e.g. BUILD)
Internal grants for research
Training for administrative leadership
Incentives to develop new courses
Incentives to integrate new technology into your classroom
Incentives to integrate culturally competent practices into your classroom
15. During the past year, have you engaged in any of the following activities?
(choose all that apply)
Participated in the development of science curriculum (enhancing an existing
science course or creating a new science course)
Taught a newly developed science course
Participated in the development of supplementary cultural curriculum for students
or faculty in the sciences (e.g. stereotype threat, cultural assets, cultural
competency, etc.)
Taught a newly developed supplemental cultural course for students or faculty in
the sciences
Been evaluated for tenure or promotion
Participated in self-evaluation for tenure or promotion
OMB #0925-XXXX
EXP. XX/XXXX
16. In how many of the courses that you teach do you use each of the
following?
All
Most
Some
None
a. Student presentations
4
3
2
1
b. Student evaluations of each
others’ work
4
3
2
1
c. Class discussions
4
3
2
1
d. Cooperative learning (small
groups)
4
3
2
1
e. Experiential learning/Field
studies
4
3
2
1
f.
4
3
2
1
g. Group projects
4
3
2
1
h. Student-selected topics for
course content
4
3
2
1
i.
Reflective writing/journaling
4
3
2
1
j.
Using student inquiry to drive
learning
4
3
2
1
4
3
2
1
Demonstrations
k. Peer-led activities
OMB #0925-XXXX
EXP. XX/XXXX
17. How confident are you that you can do the following:
Extremely
Confident
Very
Confident
Somewhat
Confident
Slightly
Confident
Not at all
Confident
a. Setting learning goals
1
2
3
4
5
b. Selecting reading materials
1
2
3
4
5
c. Designing assignments
1
2
3
4
5
d. Planning class activities
1
2
3
4
5
e. Using various teaching strategies
1
2
3
4
5
f.
Engaging students in learning
1
2
3
4
5
g. Providing students opportunities to
practice skills
1
2
3
4
5
h. Promoting student collaboration
1
2
3
4
5
i.
Encouraging students to ask questions
1
2
3
4
5
j.
Encouraging students to express ideas
1
2
3
4
5
k. Encouraging participation from women
and minorities
1
2
3
4
5
l.
Accurately assessing students’
knowledge
1
2
3
4
5
m. Grading assignments using criteria
1
2
3
4
5
n. Providing students constructive
suggestions
1
2
3
4
5
o. Providing students with prompt feedback
1
2
3
4
5
p. Fostering students’ independent thinking
1
2
3
4
5
q. Addressing sensitive issues in ways that
help students to deal with them maturely
1
2
3
4
5
r.
1
2
3
4
5
s. Providing students an overview of
discipline
1
2
3
4
5
t.
1
2
3
4
5
u. Staying current in subject knowledge
1
2
3
4
5
v. Helping students understand the
relevance of learning
1
2
3
4
5
Fostering students’ confidence in ability
to learn
Demonstrating passion for teaching
OMB #0925-XXXX
EXP. XX/XXXX
w. Enriching teaching with research
1
2
3
4
5
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.
18. Have you ever regularly mentored students, junior faculty, junior
researchers, or peers on biomedical career or research issues?
No
Yes
a. About how many people have you mentored in the past five years?
19. Do you have anyone you currently mentor who is junior to you (students,
junior faculty, junior researchers)?
No
Yes
Back
Next
Cancel
OMB #0925-XXXX
EXP. XX/XXXX
20. How many different people do you regularly mentor currently? (Enter 0 if
you do not mentor anyone in a category.)
a. Undergraduate Students: _____
b. Graduate Students: _____
c. Post-docs: _____
d. Junior faculty or junior researchers: _____
e. Others: _____
21. Which of the following do you help your mentees 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)
Personal support (e.g. listening to personal concerns)
Other (specify): ________________________________
22. How did you first connect with your mentees? (choose all that apply)
They were assigned by your department or campus
Through a NRMN mentorship program
Matched through some other formal program
They sought you out independently
Other (specify): _________________
23. How do you usually communicate with your mentees?
In-person
Phone/Skype
Email/Text
Other (specify): _____________________
OMB #0925-XXXX
EXP. XX/XXXX
24. On average, how often do you usually communicate with your mentees
about their research?
Weekly or more often
Monthly
Several times a year
Annually or less
25. For the two mentees with whom you work most closely on your research,
please use the following private weblink to provide the name and email for
those mentees. Weblink will not allow anyone to view the name or email
address. Information will be used to email a request to these mentees to
complete a brief survey regarding their mentored experience. Mentee name
and email are only available to our research office if the mentee elects to
respond to the email request by going to the website and completing the
survey. Their information will be deleted from the system after 3 months if they
do not respond to the requests to participate.
26. Do you have anyone you currently mentor who is at a similar career level
to yours (a peer)?
No
Yes
27. How many different peers do you mentor currently? ____
OMB #0925-XXXX
EXP. XX/XXXX
28. Which of the following do you help your peers with? (choose all that
apply)
Research issues
Social and emotional needs, e.g. sharing concerns about career and
work-life balance
Tangible help, e.g. advice about faculty colleagues and teaching, 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): _________________
29. How did you first connect with these peers? (choose all that apply)
They were assigned by your department or campus
Through a NRMN mentorship program
Matched through some other formal program
They sought you out independently
Other (specify): _________________
30. How do you communicate with your peer mentees?
In-person
Phone/Skype
Email/Text
Other (specify): _____________________
OMB #0925-XXXX
EXP. XX/XXXX
31. On average, how often do you usually communicate with these peers
about their research?
Weekly or more often
Monthly
Several times a year
Annually or less
32. For the two peers whom you mentor most, please use the following
private weblink to provide the name and email for those mentees.
Weblink will not allow anyone to view the name or email address.
Information will be used to email a request to these mentees to complete
a brief survey regarding their mentored experience. Mentee name and
email are only available to our research office if the mentee elects to
respond to the email request by going to the website and completing the
survey. Their information will be deleted from the system after 3 months
if they do not respond to the requests to participate.
33. Do you have a faculty member or someone else who is more senior than
you who you currently consider a mentor?
No
Yes
34. How many different mentors do you regularly work with? __
35. 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)
Personal support (e.g. listening to personal concerns)
Other (specify): _________________
OMB #0925-XXXX
EXP. XX/XXXX
36. How did you find this mentor?
They were assigned by your department or campus
Through NRMN
Matched through some other formal program
You sought out your mentor independently
Other (specify): _________________
37. How do you communicate with your primary mentor? (Choose all that
apply)
In-person
Phone/Skype
Email/Text
Other (specify): _____________________
38. How often do you usually communicate with your primary mentor
about your research?
Weekly or more often
Monthly
Several times a year
Annually or less
Back
Next
Cancel
OMB #0925-XXXX
EXP. XX/XXXX
39. Do you have someone at a similar educational level as you (i.e. a peer)
who you currently consider a mentor?
No
Yes
40. How many different peer mentors do you have? ____
41. Which of the following do your primary peer mentors help you with?
(choose all that apply)
Research issues
Social and emotional needs e.g. sharing concerns about career and
work-life balance
Tangible help (e.g. advice about faculty colleagues and teaching, 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): _________________
44. How did you find this primary mentor?
They were assigned by your department or campus
Through NRMN
Matched through some other formal program
You sought out your mentor independently
Other (specify): _________________
OMB #0925-XXXX
EXP. XX/XXXX
43. How do you usually communicate with your primary peer mentor?
In-person
Phone/Skype
Email/Text
Other (specify): ______________________________________
44. How often do you usually communicate with your primary peer
mentor?
Weekly or more often
Monthly
Several times a year
Annually or less
OMB #0925-XXXX
EXP. XX/XXXX
45. During the past year, have you engaged in any of the following activities?
(Choose all that apply)
Yes
No
a. Participated in a mentor training program, as an attendee
(preparation to mentor)
b. Participated in a mentee training program, as an attendee
(preparation to be mentored)
c. Participated in the development of mentoring program
curriculum for students or faculty
d. Led/Taught a mentor training program
e. Led/Taught a mentee training program
f.
Accessed the National Research Mentoring Network
(NRMN) resource
g. Mentored at least one undergraduate student
h. Mentored at least one graduate student
i.
Been mentored by at least one professional in my field
46. In the past year, to what extent have you:
To A Great
Extent
To Some
Extent
Not at All
a. Engaged in a research project
directed by others
1
2
3
b. Worked with undergraduates
on a research project
1
2
3
c. Worked with graduate
student(s) on a research
project
1
2
3
d. Engaged in your own research
project
1
2
3
e. Engaged undergraduates on
your own research project
1
2
3
1
2
3
1
2
3
f.
Engaged graduate students on
your research project
g. Engaged in public discourse
about your research or field of
study (e.g. blog, media
interviews, op-eds, etc.)
N/A
OMB #0925-XXXX
EXP. XX/XXXX
47. Please rate how skilled you feel you are in each of 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 di fferent
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 e ffectively with
your mentees ’ other mentor
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 di fferences
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 to 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
OMB #0925-XXXX
EXP. XX/XXXX
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 your 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
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
1
2
3
4
5
6
7
N/A
z. Helping your mentees
acquire resources (e.g. grants,
etc.)
1
2
3
4
5
6
7
N/A
48a. In your mentoring relationship, how important is it to you that YOU do the following:
Not at all
important
Somewhat
important
Very
Important
a. Discussing diversity issues
1
2
3
N/A
b. Considering my own cultural
background as well as my mentee’s
cultural background
1
2
3
N/A
c. Valuing and respecting cultural
differences
1
2
3
N/A
48b. 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
OMB #0925-XXXX
EXP. XX/XXXX
48c. 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
49. Please respond to the following statements about your primary mentee that you
have worked with in the past year.
This is not one
of my
mentoring
objectives
I have considered
how to include
this in my
mentoring
I have tried to do
this in my
mentoring
I have evidence I
have done this
effectively in my
mentoring
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
g. My mentor and I
developed a relationship
based on trust.
1
2
3
4
h. My mentor understood
how I learn best.
1
2
3
4
i. My mentor created an
environment that allowed
me to achieve my goals.
1
2
3
4
j. My mentor and I
discussed diversity issues.
1
2
3
4
k. My mentor seemed so
busy that I was afraid to
interrupt him/her.
1
2
3
4
l. My mentor had an
effective mentoring style.
1
2
3
4
m. My mentor acted as a
positive role model.
1
2
3
4
n. My mentor showed
interest in me as a person.
1
2
3
4
OMB #0925-XXXX
EXP. XX/XXXX
o. My mentor expressed
consideration for his/her
cultural background as
well as my own.
1
2
3
4
p. My mentor fostered my
independence.
1
2
3
4
q. My mentor fostered
confidence in my skills.
1
2
3
4
r. My mentor appreciated
my contributions.
1
2
3
4
s. My mentor encouraged
me to be creative.
1
2
3
4
t. My mentor made me
enthusiastic about my
project.
1
2
3
4
u. My mentor helped me
feel curious about my
project.
1
2
3
4
v. My mentor treated me
as a colleague.
1
2
3
4
w. My mentor helped me
decide on a career path.
1
2
3
4
x. My mentor
communicated his/her
expectations of me.
1
2
3
4
y. My mentor respected
my goals.
1
2
3
4
z. My mentor allowed me
to take ownership in my
research.
1
2
3
4
aa. My mentor created an
environment where I felt
safe to make mistakes.
1
2
3
4
bb. My mentor made me
feel included in the lab.
1
2
3
4
cc. My mentor valued and
respected cultural
differences.
1
2
3
4
dd. My mentor regularly
assessed skills and
knowledge that I gained in
the lab
1
2
3
4
OMB #0925-XXXX
EXP. XX/XXXX
Research, Grants, and Career Activity
50. Below is a list of all grants and submissions you have provided to us in the
past.
Since you last provided us with information, have you applied for any
additional grant funding or other financial support for your research (either
as Principal Investigator or as Co-Investigator or other paid position) that is
not on the list OR has the status of previous submissions changed?
No
Yes
51. Please complete or update information for each grant or proposal:
a. Funding Agency Type:
NIH
Other federal (e.g. NSF)
Nonfederal governmental
Nonprofit (e.g. foundations)
For-profit
Other (specify): ____________
b.
c.
Full grant number if available ____________________________
Agency/Foundation/Company Name: __________________
d. Role:
Principal Investigator
Co-PI
OMB #0925-XXXX
EXP. XX/XXXX
Investigator
Other (specify): _____________
e. Your percent effort: ____% or ____ calendar months
f. Submission status:
Submitted (first time for this proposal)
Re-submitted with revisions
Not funded
NIH Impact score (if applicable): ______
Funded
NIH Impact score (if applicable): ______
g. Project Title: __________________
h. Annual direct cost (average across all years) :
Less than $50,000
$50,000-$99,999
$100,000-$249,999
$250,000-$499,999
$500,000 or more
i. Start Date (e.g., 07/08/2015)
j. End Date
(e.g., 07/08/2016)
Back
Cancel
Next
OMB #0925-XXXX
EXP. XX/XXXX
k. Grant funding mechanism:
K (any type)
P (any type)
R01
R03 or R21
Other R series
T (any type)
U (any type)
Other (e.g., supplements, etc) (specify): ____________
l. 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
52.Have you conducted research that is not covered by the grants listed
above?
No
Yes
a. What type of research was this? (select all that apply)
Literature review, synthesis of existing knowledge, and/or conceptual
Analysis of existing (secondary) data
Analysis of data you collect (primary analysis)
c. What was your role? (select all that apply)
PI /Co-PI or Project Lead
Investigator
Other (Specify): __________________________________
53.Do you have any peer-reviewed publications accepted, in-press, or
published in the past year? This may include peer-reviewed abstracts
included in conference proceedings.
No
Yes
54.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? This may include peer-reviewed abstracts included in
conference proceedings.
No
Yes
OMB #0925-XXXX
EXP. XX/XXXX
If yes, please answer the following questions:
a. PMID # if available: ________________List all Authors (Last FM, comma
separated): ______, ______, ______, ______
b. Title: __________________
c. Journal Name: __________________
d. Year Published (or indicate “in press” or “epub ahead”): ________
e. Volume: ______
f. Issue: ______
g. Page Numbers: ______
h. DOI or URL for epubs: ____________________
55. Are there other scientific publications of yours to add to this list? (e.g.
book chapters, books, reports, non-peer reviewed journal articles,
working papers, other)
No
Yes
a. Publication Type:
Chapter
Book
Other, specify: ____________
b. List all Authors (Last FM, comma separated): ______, ______, ______,
OMB #0925-XXXX
EXP. XX/XXXX
Complete the applicable information below depending on publication type:
c. Book/Anthology Title: __________________
d. Chapter Title : __________________
e. Editors: __________________
f. Year Published: ______
g. Edition: ______
h. Publisher: ________________
i. City: ________________
j. State: __________
k. Page Numbers: ______
l. DOI or URL for epubs: ____________________
56.Have you presented at a scientific conference in the last year (including
posters)?
No
Yes
a. Was this a conference publication with:
Undergraduate student(s)
Graduate student(s)
57.Please provide information about any of your technology transfer
activities.
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
OMB #0925-XXXX
EXP. XX/XXXX
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): _____________________
58. 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:
Yes
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?
No
OMB #0925-XXXX
EXP. XX/XXXX
59.In the past year, have you been formally recognized, honored, or
awarded in recognition of your teaching, research, or other professional
activity?
No
Yes
If yes, please list any honors or awards you received in the past year in
recognition of your teaching, research, or other professional activity:
60.Have you held office in any professional organization in the past year?
No
Yes
If yes, please list any offices you have held in professional organizations
in the past year:
61.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
OMB #0925-XXXX
EXP. XX/XXXX
If yes, please list any service to federal agencies you have performed in
the past year (e.g. reviewer for NIH/NSF/CDC or similar proposals,
member of federal agency advisory council, etc.):
62.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
63. We would like to know how confident you are today that you can successfully
perform the tasks listed below. Using a 0-10 scale, indicate your level between No
Confidence (0) and Total Confidence (10) in your current abilities in these general
areas of research and grant writing. Use NA when a task statement does not seem
appropriate for your training.
No Confidence
Total Confidence
a. Select a suitable
topic area for study.
0
1
2
3
4
5
6
7
8
9
10
N/A
b. Refine a problem
so that it can be
investigated.
0
1
2
3
4
5
6
7
8
9
10
N/A
c. Develop a logical
rationale for a
particular research
idea.
0
1
2
3
4
5
6
7
8
9
10
N/A
d. Organize your
proposed research
ideas in writing.
0
1
2
3
4
5
6
7
8
9
10
N/A
e. Articulate a clear
purpose for the
research.
0
1
2
3
4
5
6
7
8
9
10
N/A
f. Place your study in
the context of existing
research and justify
how it contributes to
important questions in
the area.
0
1
2
3
4
5
6
7
8
9
10
N/A
g. Relate your specific
questions of interest
to underlying theory.
0
1
2
3
4
5
6
7
8
9
10
N/A
h. Convince grant
reviewers your
proposed study is
worth funding.
0
1
2
3
4
5
6
7
8
9
10
N/A
i. Choose an
appropriate research
design that will
answer a set of
research questions
and/or test a set of
hypothesis.
0
1
2
3
4
5
6
7
8
9
10
N/A
j. State the purpose,
strengths, and
limitations of each
study design.
0
1
2
3
4
5
6
7
8
9
10
N/A
k. Determine the
universe, population,
and appropriate
sample for a given
study.
0
1
2
3
4
5
6
7
8
9
10
N/A
OMB #0925-XXXX
EXP. XX/XXXX
l. Determine an
adequate number of
subjects for your
research project.
0
1
2
3
4
5
6
7
8
9
10
N/A
m. Select methods of
data collection
appropriate to the
study population and
variable(s) of interest.
0
1
2
3
4
5
6
7
8
9
10
N/A
n. Determine how
each variable will be
measured.
0
1
2
3
4
5
6
7
8
9
10
N/A
o. Design the best
data analysis strategy
for your study.
0
1
2
3
4
5
6
7
8
9
10
N/A
p. Identify appropriate
funding sources (local,
state, national) to
support a study.
0
1
2
3
4
5
6
7
8
9
10
N/A
q. Speak with a
person at the funding
agency regarding your
project or project
ideas.
0
1
2
3
4
5
6
7
8
9
10
N/A
r. Describe a major
funding agency's
(e.g., NIH, foundation)
proposal review and
award process.
0
1
2
3
4
5
6
7
8
9
10
N/A
s. Write a competitive
grant application.
0
1
2
3
4
5
6
7
8
9
10
N/A
t. Write-up research
findings for publication
in a peer-reviewed
journal.
0
1
2
3
4
5
6
7
8
9
10
N/A
u. Conduct the
appropriate statistical
analyses to answer
your research
questions.
0
1
2
3
4
5
6
7
8
9
10
N/A
v. Summarize
research findings in a
traditional research
report.
0
1
2
3
4
5
6
7
8
9
10
N/A
OMB #0925-XXXX
EXP. XX/XXXX
w. Summarize and
highlight research
findings for publication
in a peer-reviewed
journal.
0
1
2
3
4
5
6
7
8
9
10
N/A
x. Communicate key
research findings to a
wide audience of
stakeholders.
0
1
2
3
4
5
6
7
8
9
10
N/A
y. Submit paper and/
or poster
presentations to
conferences related to
your topic area.
0
1
2
3
4
5
6
7
8
9
10
N/A
z. Present research
findings at
conferences related to
your topic area.
0
1
2
3
4
5
6
7
8
9
10
N/A
OMB #0925-XXXX
EXP. XX/XXXX
YEAR 4 ADDITIONAL ITEMS
Institutional Priority: Commitment to Diversity
1. Indicate how important you believe each priority listed below is at your
college or university:
Low Priority
Medium
Priority
High
Priority
Highest
Priority
a. To recruit more minority
students
1
2
3
4
b. To create a diverse multicultural campus environment
1
2
3
4
c. To increase the representation
of minorities in the faculty and
administration
1
2
3
4
d. To increase the representation
of women in the faculty and
administration
1
2
3
4
e. To develop an appreciation for
multiculturalism
1
2
3
4
OMB #0925-XXXX
EXP. XX/XXXX
2. Below are some statements about your college or university. Indicate the
extent to which you agree or disagree with each of the following.
Disagree
Strongly
Disagree
Somewhat
Agree
Somewhat
Agree
Somewhat
a. Faculty are interested in
students’ personal problems.
1
2
3
4
b. Racial and ethnic diversity is
reflected in the curriculum.
1
2
3
4
c. Most students are wellprepared academically
1
2
3
4
d. This institution has effective
hiring practices and policies
that increase faculty diversity.
1
2
3
4
e. This institution takes diversity
of faculty into consideration as
part of the promotion process.
1
2
3
4
1
2
3
4
g. Faculty are committed to the
welfare of this institution.
1
2
3
4
h. Faculty here are strongly
interested in the academic
problems of undergraduates.
1
2
3
4
f.
Student Affairs staff have the
support and respect of faculty.
i.
There is a lot of campus racial
conflict here.
1
2
3
4
j.
My research is valued by
faculty in the department.
1
2
3
4
k. My teaching is valued by
faculty in the department.
1
2
3
4
1
2
3
4
m. This institution takes into
consideration quality mentoring
efforts by faculty as part of the
promotion process.
1
2
3
4
n. Faculty are sufficiently involved
in campus decision making.
1
2
3
4
l.
My service is valued by faculty
in the department.
OMB #0925-XXXX
EXP. XX/XXXX
o. This institution takes
responsibility for educating
underprepared students.
1
2
3
4
p. The criteria for advancement
and promotion decisions are
clear.
1
2
3
4
q. Most of the students I teach
lack the basic skills for college
level work.
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
r.
There is adequate support for
faculty development.
s. This institution successfully
educates students in remedial/
developmental education.
t.
Faculty are not prepared to
deal with conflict over diversity
issues in the classroom.
3. Previously, you had indicated you are marital status. Has that changed?
No
Yes
Please indicate your current marital status: (Check one)
Single
In a civil union
In a domestic partnership
Married
Unmarried, living with partner
Separated
Divorced
Widowed
4. How many children do you have in the following age ranges?
0, 1, 2, 3, 4+
Under 18 years old: __________
18 years or older: __________
OMB #0925-XXXX
EXP. XX/XXXX
5. Do you have any of the following disabilities or medical conditions?
Yes
No
Yes
No
a. Learning disability (dyslexia, etc.)
b. Attention deficit hyperactivity disorder (ADHD)
c. Autism spectrum/Asperger’s syndrome
d. Physical disability (speech, sight, mobility, hearing, etc.)
e. Chronic illness (cancer, diabetes, autoimmune disorders, etc.)
f.
Psychological disorder (depression, etc.)
Other (please specify): _______________________
6. Please indicate “Yes” or “No” for each of the following:
Yes, No
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
sometimes or often 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?
7. Please enter your base institutional salary (e.g., for $56,000, please enter
56000): $__________
Part Time Faculty (question #7a)
7a.Please enter your total salary from teaching at this institution for this
academic year (e.g., for $30,000, please enter 30000): $_________
OMB #0925-XXXX
EXP. XX/XXXX
8. Your base institutional salary reported above is based on (Check one):
Less than 9 months
9/10 months
11/12 months
Part Time Faculty
8a.How much are you paid per course at this institution (e.g., for $3,000, please
enter 3000): $_________
9. What percentage of your current year’s income comes from: (e.g. for 45%,
please enter 45 and total for all responses must equal 100%)
Base salary from this institution
______%
Other income from this institution
______%
Income from another academic institution
______%
Non-academic income
______%
Back
Next
Cancel
| File Type | application/pdf |
| File Modified | 2016-06-02 |
| File Created | 2016-01-11 |