Protocols for Paper Survey

ATTACHMENT B.3: Paper sURVEY for EARLY INDEPENDENCE Principal Investigators

Last Name, First Name: Institution: Date:

AGREEMENT TO PARTICIPATE

The Common Fund of the National Institutes of Health (NIH) is doing a process evaluation of its Early Independence Award (EIA) program. An independent Company, XXX, has been contracted to conduct the process evaluation. The purpose of this evaluation is to assess how the program is being implemented, assess progress being made by the EIA Principal Investigators, and assess support being provided to the Principal Investigators by the Host Institution.

The survey provides an opportunity to gather Principal Investigators’ general expectations for the EIA program at the beginning of their first year of award. The information gathered will be used to document the EIA program operations, and to improve the program and guide future strategic and management decisions. The survey should take approximately 30 minutes to complete.

Your participation is entirely voluntary- You are under no obligation to interview with us, but we strongly encourage you to do so. A successful evaluation of the EIA program depends on a high response rate to gather as much information and as many perspectives as possible. There are no consequences or risks for participating. Refusal to participate will involve no penalty or loss of benefits to which you are otherwise entitled, and you may discontinue the interview at any time without penalty or loss of benefits to which are otherwise entitled.

Your responses will be kept private- Your participation is voluntary and non-participation will have no impact on you or your institution. If you choose to participate, your responses will be kept private under the Privacy Act, and will not be disclosed to anyone but the researchers conducting this study, except as otherwise required by law. You will not be identified by name and information from the study will only be reported in the aggregate. Your responses will be combined with those of other respondents in the final report.

Whom to contact for additional information- For additional information about the study you may contact: XXXXXX.

Public reporting burden for this collection of information is estimated to average 30 minutes, including the time for reviewing instructions, searching existing data sources, gather 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 to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0534). Do not return the completed form to this address.

Agree to Participate

Yes, I agree to participate. Thank You. Your participation is greatly appreciated.

No, I am not interested in participating. Thank You