Form 12 NRMN Student Mentee Core Followup Survey

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Attachment 18:

NRMN Student/Mentee Core Follow-up Survey

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NRMN Mentee Annual Follow-up Survey
You have been selected to be a part of a national study 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. 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.

The National Research Mentoring Network has provided UCLA your name and contact information because you have participated in activities 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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Thank you for responding to this information request. We already have basic information about you from your NRMN registration, but there are a few additional items
we need about your professional experience.
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

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A. Current position
First, we would like to ask you about any current school or work activities.
6. 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

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7. 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
e. Volunteer
Position: _________________
Company: _________________

No volunteer position

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f. Is this volunteer position related to research?
No
Yes
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?
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
e. Status of application:
Accepted and will attend
Accepted and will not attend
Waitlisted

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Pending
Not accepted

10. 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): ________________

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11. 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
12. Please attach your most recent academic vita (such as a CV)

Upload

13. Please tell us which of the following activities you participated in since
date of last contact?. 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 cour-ses, 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)

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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.
14. Do you have a faculty member or someone else who is more senior than
you who you consider a mentor?
No
Yes
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
Monthly
Several time a year
Annually or less

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f. How did you find this mentor?
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): ______________
15. 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?
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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16. 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): ______________
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)
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): _________________

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17. 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)
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)
They were assigned in some other way by your department or campus
You were matched through the National Research Mentoring Net-work (NRMN)
Matched through some other formal program
They sought you out independently
Other (specify): _________________

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C. Research and Grants
18.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

19. 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

20. 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

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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
21. 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. If Nonfede ral, Nonprofit, For-Profit, Other
Agency/Foundation/Company Name: __________________
d. Role:
Principal Investigator
Co-Principal Investigator
Investigator

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Other (specify): _____________
e. 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): ______
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): _____________________

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22. 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): __________________________________

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23. Do you have any peer-reviewed publications accept
ed, 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 all Authors (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: ____________________

24. 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

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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. Editors: __________________
f. Year Published: ______
g. Edition: ______
h. Publisher: ________________
i. City: ________________
j. State: ___
k. Page Numbers: ______
l. DOI or URL for epubs: ____________________

25. Have you presented at a scientific conference in the last year (including
posters)?
No
Yes

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26. 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:

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27. In the past year, have you been formally recognized, honored, or awarded in recognition of your 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:

28. Have you held office in any pre-professional or professional 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:

29. 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:

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30. 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:

31. 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

32. Indicate to what extent the following statements are true of you:
Strongly Disagre
Disagree
e

Neutr
al

Agree

Strongl
y
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

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33. Indicate to what extent you are confident that you can complete the following
tasks:
Not at
all
confide
nt

A little
confiden
t

Somewh
at
Confiden
t

Very
Confide
nt

Absolutel
y
Confiden
t

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)

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34. 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

35. 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

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37. 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?

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No