Form 11 NMA Academic Career Development Workshop Contact Info an

Office of Minority Health Research Coordination (OMHRC) Research Training and Mentor Programs Applications (NIDDK)

(11) NIH NMA Academic Career Development Workshop Contact Info and Feedback Form

NIH/NMA Academic Career Development Workshop Contact Information and Feedback Form

OMB: 0925-0748

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NIH/National	Medical	Association	(NMA)	Academic	Career	Development
Workshop	Contact	Information	and	Feedback	Form

For	past	recipients	of	the	NIH/NMA	travel	award,	please	provide	the	most	up-to-date
contact	information	and	feedback.

OMB No: 0925-0748
Expiration date: XX/XX/XXXX
Collection	of	this	information	is	authorized	by	The	Public	Health	Service	Act,	
Section	411	(42	USC	285a).	Rights	of	study	participants	are	protected	by	The	Privacy	
Act	of	1974.	Participation	is	voluntary,	and	there	are	no	penalties	for	not	
participating	or	withdrawing	from	the	study	at	any	time.	Refusal	to	participate	will	
not	affect	your	benefits	in	any	way.	The	information	collected	in	this	study	will	be	
kept	private	to	the	extent	provided	by	law.	Names	and	other	identifiers	will	not	
appear	in	any	report	of	the	study.	Information	provided	will	be	combined	for	all	
study	participants	and	reported	as	summaries.	You	are	being	contacted	by	an	on-line	
website	to	complete	this	instrument	so	that	we	can	obtain	updated	contact	
information.
Public	reporting	burden	for	this	collection	of	information	is	estimated	to	average	5	
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	0MB	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	(0925-0748).	Do	
not	return	the	completed	 form	to	this	address.
* 1.	Contact	information:
Name
Institution/Organiza
tion
Position	Title
Business	Address	
City/Town
State/Province
ZIP/Postal	Code
Email	Address
Phone	Number

NIH/National	Medical	Association	(NMA)	Academic	Career	Development
Workshop	Contact	Information	and	Feedback	Form

2. Is	your	current	position	in	academic	medicine	or	biomedical	research?
Yes
No
Other	(please	specify)

NIH/National	Medical	Association	(NMA)	Academic	Career	Development
Workshop	Contact	Information	and	Feedback	Form

3. Did	attending	the	NIH/NMA	Academic	Career	Development	Workshop	influence	your
decision	in	pursuing	a	career	in	academic	medicine	or	biomedical	research?
Yes
No
Other	(please	specify)

NIH/National	Medical	Association	(NMA)	Academic	Career	Development
Workshop	Contact	Information	and	Feedback	Form

4. What	aspects	of	the	NIH/NMA	Academic	Career	Development	Workshop	were	most
valuable	to	you	(e.g.,	session	topics,	networking,	small	group	discussions	with	NMA	faculty,
etc.)?

NIH/National	Medical	Association	(NMA)	Academic	Career	Development
Workshop	Contact	Information	and	Feedback	Form

Thank	you	for	providing	us	with	your	updated	information	and	feedback!


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