OMB-F07 - UGSP Payback Feedback

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UGSP EVALUATION OF SCHOLAR PAYBACK PERIOD
OMB Number: 0925-0299 
Expiration Date: 31 March 2027
Burden Time: 10 minutes

Collection of this information is authorized by The Public Health Service Act, Section 410 (42 USC 285). Rights of participants are protected by The Privacy Act of 1974. Completion of this collection form is voluntary and there are no penalties for not participating or withdrawing at any time. The collection information will be kept private to the extent provided by law. Information provided will be covered by the following SORNs: OPM/GOVT-1, OPM/GOVT-5, 09-90-0020, 09-25-0014, 09-25-0108, 09-25-0140, 09-25-0158, and 09-25-0165.

Public reporting burden for this collection of information is estimated to average 10 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 (0925-0299). Do not return the completed form to this address.


Q1 First Name (Given Name):
________________________________________________________________


Q2 Last Name (Family Name)
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Q3 Type of Service Completed
    • Summer Service
    • Year Service


Q4 Service Period Start Date (ex: 15 Jun 2024)
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Q5 Service Period Stop Date (ex: 15 Aug 2024)
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Q6 Indicate the strengths of this scholar using these categories:

Top 1% 
Top 10%
Top 33%
Top 50%
Bottom 50%
N/A
Interest in Science
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Ability to Complete Projects Accurately and Timely
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Writing Skills
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Analytical Problem-Solving Skills
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Oral Communication Skills
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Ability to Work Independently
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Rapport with Peers
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Rapport with Faculty or Supervisor
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Initiative 
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Curiosity 
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Creativity 
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Observation Skills
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Q7 Assess the scholar's potential for a career in biomedical research and share any observation and inferences that would be useful in predicting this scholar's potential to become a biomedical, behavioral, or social science health related researcher.  
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Q8 Do you have any reason to believe this scholar may not satisfy the post-graduation service requirement?
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EVALUATOR INFORMATION

Q9 First Name (Given Name)
________________________________________________________________


Q10 Last Name (Family Name)
________________________________________________________________


Q11 Email Address (check accuracy)
________________________________________________________________


Q12 Signature Block
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