Form 13 NRMN Faculty Mentor Core Followup Survey

OMB #0925-XXXX
EXP. XX/XXXX

Attachment 17:

NRMN Faculty Core Follow-up Survey

OMB #0925-XXXX
EXP. XX/XXXX

NRMN Mentor Annual Tracking Survey
The National Research Mentoring Network (NRMN) 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 research careers. This large
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 on behalf of the Consortium and NIH.

NRMN 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.
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

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

Defer for now

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

Back

Next

Cancel

OMB #0925-XXXX
EXP. XX/XXXX

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.
12. 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?
13. Do you have anyone you currently mentor who is junior to you (students,
junior faculty, junior researchers)?
No
Yes

14. 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: _____

OMB #0925-XXXX
EXP. XX/XXXX

15. 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): ________________________________
16. 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): _________________
17. How do you usually communicate with your mentees?
In-person
Phone/Skype
Email/Text
Other (specify): _____________________
18. 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
19. 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. [

Link

OMB #0925-XXXX
EXP. XX/XXXX

20. Do you have anyone you currently mentor who is at a similar career level
to yours (a peer)?
No
Yes

21. How many different peers do you mentor currently? ____
22. 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): _________________
23. 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): _________________
24. How do you communicate with your peer mentees?
In-person
Phone/Skype
Email/Text
Other (specify): _____________________

OMB #0925-XXXX
EXP. XX/XXXX

25. 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

26. 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.

Link

Back

Next

Cancel

OMB #0925-XXXX
EXP. XX/XXXX

27. Do you have a faculty member or someone else who is more senior than
you who you currently consider a mentor?
No
Yes

28. How many different mentors do you regularly work with? __
29. 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): _________________
30. 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): _________________
31. How do you communicate with your primary mentor? (Choose all that
apply)
In-person
Phone/Skype
Email/Text
Other (specify): _____________________

OMB #0925-XXXX
EXP. XX/XXXX

32. 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
33. Do you have someone at a similar educational level as you (i.e. a peer)
who you currently consider a mentor?
No
Yes

34. How many different peer mentors do you have? ____

35. 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): _________________

Back

Next

Cancel

OMB #0925-XXXX
EXP. XX/XXXX

36. 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): _________________
37. How do you usually communicate with your primary peer mentor?
In-person
Phone/Skype
Email/Text
Other (specify): __________________
38. How often do you usually communicate with your primary peer
mentor?
Weekly or more often
Monthly
Several times a year
Annually or less

Back

Next

Cancel

OMB #0925-XXXX
EXP. XX/XXXX

Professional Development

39. In the past year, have you participated in any training not through NRMN
to improve your skills as a mentor?
Since we last contacted you on date, have you participated in any training
not through NRMN to improve your skills as a mentor?
No
Yes

a. Type of training (Select all that apply)
In-person
On-line that occurs in scheduled, real-time method (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)
Other (Specify): _______________

b. Approximately how many hours was your training over the past year?
_____hours

OMB #0925-XXXX
EXP. XX/XXXX

40. In the past year, have you participated in any training not through NRMN
to improve your skills as a mentee?
Since we last contacted you on date, have you participated in any training
not through NRMN to improve your skills as a mentee?

No
Yes

c. Type of training (Select all that apply)
In-person
On-line that occurs in scheduled, real-time method (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)
Other (Specify): ____________________________

d. Approximately how many hours was your training over the past year?
_____hours

OMB #0925-XXXX
EXP. XX/XXXX

41. Have you completed formal training/workshops related to your career or
research (minimum of at least 4 hours cumulative duration) in addition to those
offered by NRMN?

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?

Back

Next

Cancel

No

OMB #0925-XXXX
EXP. XX/XXXX

Research, Grants, and Career Activity
42. 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

43. 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. Full grant number if available
c.

Agency/Foundation/Company Name: __________________

d. Role:
Principal Investigator
Co-PI
Investigator
Other (specify): _____________

OMB #0925-XXXX
EXP. XX/XXXX

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

Back

Next

(e.g., 07/08/2016)

Cancel

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): _____________________

Back

Next

Cancel

OMB #0925-XXXX
EXP. XX/XXXX

44. 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): _________________________

Back

Next

Cancel

OMB #0925-XXXX
EXP. XX/XXXX

45. 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
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
If yes, please answer the following questions:
a. PMID # if available: ________________
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: ____________________
46. 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

OMB #0925-XXXX
EXP. XX/XXXX

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: ____________________

Back

Next

Cancel

OMB #0925-XXXX
EXP. XX/XXXX

47. Have you presented at a scientific conference in the last year (including
posters)?

No
Yes

48. 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
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): _____________________

OMB #0925-XXXX
EXP. XX/XXXX

49. 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:

50. 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:

OMB #0925-XXXX
EXP. XX/XXXX

51. 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 (e.g. reviewer for NIH/NSF/CDC or similar proposals,
member of federal agency advisory council, etc.):

52. 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:

Back

Next

Cancel