Form 1 Form

NIH/NMA Contact Information
Record ID

NIH/NMA Travel Award Program
Page 1

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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: 08/2023
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.
Contact information:
Name

Institution/Organization

Position Title

Business Address

City/Town

State/Province

ZIP/Postal Code

Personal Email Address

Phone Number

03/10/2023 9:26am

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projectredcap.org

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Is your current position in academic medicine or
biomedical research?

Please specify other position:

Did attending the NIH/NMA Academic Career Development
Workshop influence your decision in pursuing a career
in academic medicine or biomedical research?
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.)?

03/10/2023 9:26am

Yes
No
Other

__________________________________
Yes
No
Other

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projectredcap.org