Louis Stokes Alliances for Minority Participation Bridge to the Doctorate (LSAMP-BD) Monitoring System

Education and Human Resources Program Monitoring Data Collections

AttachmentF1_2012 LSAMP BD_updated 20121219

Louis Stokes Alliances for Minority Participation Bridge to the Doctorate (LSAMP-BD) Monitoring System

OMB: 3145-0226

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Attachment F1


Louis Stokes Alliances for Minority Participation Bridge to the Doctorate (LSAMP-BD)

Monitoring System


Table of Contents



LSAMP-BD: Crosswalk


Common Collection Categories



Questions

Staff and Project Participant Characteristics1

Project Implementation

Characteristics2

Project Outputs3

BASELINE DATA




Student Name (First, MI, Last)

X



Previous Name (BD students only)

X



LSAMP Institution the student was enrolled in (BD students only)

X



Bachelor’s Degree-awarding Institution (peer comparison students only)

X



LSAMP Alliance (to which the above LSAMP institution belongs) (BD students only)

X



Social Security Number (not required)

X



Student ID at the Institution (requested/optional)

X



Gender

  • Male

  • Female

  • Not reported

X



Ethnicity

  • Not Hispanic or Latino

  • Hispanic or Latino

  • Not reported

X



Race (choose one or more)

  • American Indian or Alaska Native

  • Asian

  • Black or African American

  • Native Hawaiian or Other Pacific Islander

  • White

  • Not reported

X



Disability

Yes (check yes if any of the following apply):

  • Deaf or serious difficulty hearing

  • Blind or serious difficulty seeing even when wearing glasses

  • Serious difficulty walking or climbing stairs

  • Other serious disability related to a physical, mental, or emotional condition

No

Do not wish to provide

X



Citizenship—choose one:

  • U.S. Citizen/U.S. National

  • U.S. Permanent Resident/Green Card holder

  • Other (please specify)

X



Date of bachelor's degree

Month

Year

X



Undergraduate Major (choose one or more)

  • Agricultural Science

  • Chemistry

  • Computer Science

  • Engineering

  • Environmental Science

  • Geosciences

  • Life/Biological Sciences

  • Mathematics

  • Physics/Astronomy

  • Other (please specify)

X



Undergraduate GPA

X



Undergraduate GPA Scale

4 point scale

5 point scale

X



LSAMP Level I or II Status: (BD students only)




GRE Scores

Verbal Reasoning

Quantitative Reasoning

Analytical Writing

X



Research experience during the undergraduate program-choose one

  • Yes

  • No

X



GRE Scores

Verbal Reasoning

Quantitative Reasoning

Analytical Writing


Please mark the checkbox if this student did not take the GRE

X



Date entered the STEM Graduate Program

Month Year

X



Date began receiving BD funding (BD students only)

Month Year

X



Date entered current graduate program (peer comparison students only)

Month Year

X



Did this student complete any graduate work before receiving LSAMP BD funding (BD students only)

  • Yes

  • No

X



Did this student complete any graduate work before entering the current program (peer comparison students only)

  • Yes

  • No

X



Broad Field Area




Field




Degree —Choose Degree

  • No specific degree or certificate

  • Post baccalaureate Certificate

  • Masters (including MBA)

  • Post Masters Certificate

  • Doctorate (Ph.D., D.S.C., D.Sc., Ed.D.)

  • Other professional degree (J.D., L.L.B., Th.D., M.D, DDS. etc.)

  • Other (please specify)

X



Date degree awarded

Month Year

X



If no prior graduate degrees please provide the number of graduate credits completed prior to receiving LSAMP BD funding (BD students only)

X



If no prior graduate degrees please provide the number of graduate credits completed prior to entering the current graduate program (peer comparison students only)

X



Teaching assistantship awarded prior to receiving LSAMP BD funding (BD students only)

  • Yes

  • No

X



Teaching assistantship awarded prior to entering the current graduate program (peer comparison students only)

  • Yes

  • No

X



Research assistantship awarded prior to receiving LSAMP BD funding (BD students only)

  • Yes

  • No

X



Research assistantship awarded prior to entering the current graduate program (peer comparison students only)

  • Yes

  • No

X



ANNUAL DATA




As an undergraduate, did this student participate in LSAMP activities (peer comparison students only)

  • Yes

  • No




LSAMP Level I or II Status (peer comparison students only)




Graduate Program

X



Intended Broad Major Area

X



Intended Major

X



Intended Degree (choose one or more)

  • No specific degree or certificate

  • Post baccalaureate Certificate

  • Masters (including MBA)

  • Post Masters Certificate

  • Doctorate (Ph.D., D.S.C., D.Sc., Ed.D.)

  • Other professional degree (J.D., L.L.B., Th.D., M.D, D.D.S., etc.)

  • Other (please specify)

X



From which of these sources did this student receive financial support during the current reporting period (BD students only)

NSF LSAMP BD Fellowship

Yes/No

Amount

NSF other grant/fellow

Yes/No

Program Name

Amount

Institution attending

Yes/No

Type of support

Government (federal/state/local)

Yes/No

Type of support

Private funding

Yes/No

Type of support

Other sources (please specify)

Yes/No

Amount

No financial support received

X



From which of these sources did this student receive financial support during the current reporting period (peer comparison students only)

NSF grant/fellow

Yes/No

Program Name

Other sources (please specify)

Yes/No

No financial support received

X



From which of these sources did this student receive financial support to pursue graduate studies (i.e., participate in the graduate program listed in the baseline data form) at your institution at any time BEFORE this reporting period (peer comparison students only)

NSF grant/fellow

Yes/No

Program Name

Other sources (please specify)

Yes/No

No financial support received

X



LSAMP-BD Disbursement Method —choose one (BD students only)

Monthly

Quarterly

By Semester

Yearly

X



Is the LSAMP-BD stipend or payment based on academic performance —choose one (BD students only)

Yes

No

X



Did the LSAMP BD funding end for this student during the current Reporting period—choose one: (BD students only)

Yes

No

If yes, please provide the date funding ended:

Month Year

X



Number of graduate courses credits completed during the current reporting period



X

Teaching assistantship awarded during the current reporting period

  • Yes

  • No

  • Not Applicable



X

Research Assistantship awarded during the current reporting period

  • Yes

  • No

  • Not Applicable



X

Year entered Ph.D. track - (completed 2 years of graduate coursework, equivalent to MA or MS and entered 3rd year of graduate coursework, i.e. post MS and into Ph.D. track):

  • Year:

  • Not entered to Ph.D. track



X

Thesis Proposal - Date Approved:

Month Year

Not applicable; thesis proposal is not required



X

Master’s Degree - Date Awarded:

Month Year



X

Ph.D. Qualifying Examinations - Date passed:

Month Year



X

Ph.D. Candidacy - Date attained:

Month Year



X

Dissertation Defense - Date passed:

Month Year



X

Doctoral Dissertation - Date Approved:

Month Year



X

Doctoral Degree - Date Awarded:

Month Year



X

Doctoral Dissertation Abstract



X

Did the student receive post-LSAMP BD funding to continue graduate studies during the current reporting period (BD students only)—choose one:

  • Yes

  • No


If yes, please provide funding source —choose one:

  • Institution attending

  • Government fellowship: federal/state/local

  • Private fellowship


X


Did the student leave without completing the program during the current reporting period:

  • Yes

  • No


X


If yes, please provide the date the student left the program:

Month Year


X


If he or she left, was it to continue Ph.D. elsewhere?

  • Yes

  • No

  • Don’t know


X


If he or she left to continue Ph.D. elsewhere, please provide the transfer date:

Month Year


X


Transfer institution name:



X


Graduate program at transfer institution:



X


Intended broad major area at transfer institution:



X


Intended major at transfer institution:



X


Intended degree at transfer institution:

  • No specific degree or certificate

  • Post baccalaureate Certificate

  • Masters (including MBA)

  • Post Masters Certificate

  • Doctorate (Ph.D., D.S.C., D.Sc., Ed.D.)

  • Other professional degree (J.D., L.L.B., Th.D., M.D, DDS. etc.)

  • Other (please specify)


X


Current status at transfer institution:

  • Not yet graduated, but pursuing a doctorate

  • Graduated with a doctorate

Date graduated from transfer institution:

Month Year

  • Dropped out

Date dropped out from transfer institution:

Month Year

  • Other (please specify)


X


If the student transferred, how were the responses to the transfer questions obtained?(choose one)

  • Institutional Records

  • Telephone Interviews

  • Exit Interviews

  • Web surveys

  • Email

  • Paper surveys

  • Other (please specify)


X


Please provide the permanent contact information for this student.

Student’s email address

Student’s personal email address

Address

City

State

Zip Code

Country

Phone

Ext.

X



Name and address (U.S. postal and e-mail) of a person likely to know how to reach this student after he or she graduates

Name

Relationship to this student

Email address

Address

City

State

Zip Code

Country

Phone

Ext.

X



FOLLOWUP DATA




You indicated that you left the BD program. Did you return to complete your graduate studies? (BD students only)

  • Yes

  • No


X


You indicated that you left the institution. Did you return to complete your graduate studies? (peer comparison students only)

  • Yes

  • No


X


When did you return to continue your graduate studies?

Month Year


X


If you returned to continue your graduate studies, in which program did you enroll? (choose one or more)

  • Post baccalaureate Certificate

  • Masters (including MBA)

  • Post Masters Certificate

  • Doctorate (Ph.D., D.S.C., D.Sc., Ed.D.)

  • Other professional degree (J.D., L.L.B., Th.D., M.D, D.D.S., etc.)

  • Other (please specify)


X


Graduate program


X


Intended broad major area


X


Intended major


X


Did you return to [student’s original institution name]?

  • Yes

  • No


X


If No, please provide the name of the institution in which you enrolled:


X


Please mark the checkbox if no followup data are available for this individual

X



Did you receive financial support for your M.S./Ph.D. from the following sources? (BD students only)

NSF LSAMP BD Fellowship

Yes/No

Amount

NSF other grant/fellow

Yes/No

Program Name

Amount

Institution attending

Yes/No

Type of support

Government (federal/state/local)

Yes/No

Type of support

Private funding

Yes/No

Type of support

Other sources (please specify)

Yes/No

Amount

No financial support received

X



Have you received a post doctorate appointment —choose one

Yes

No


If yes, please complete the following items

Date: Month Year

Institution

Department

Field



X

Are you currently employed —choose one

  • Yes

  • No



X

When did you begin this job?

Month Year



X

Is this job full-time —choose one

  • Yes

  • No



X

Which of the following categories best describes your employer for this job? (choose one or more)

  • A private, for-profit company, business or individual, paying your wages, salary or commissions

  • A Private not-for-profit, tax-exempt or charitable organization

  • Self-employment in own not Incorporated business, professional practice, or farm

  • Self-employment in own incorporated business, professional practice, or farm

  • Local government (e.g., city, county)

  • State government

  • U.S. military service, active duty, or commissioned corps (e.g., USPHS, NOAA)

  • U.S. Government as a civilian employee

  • Other (please specify)



X

Regarding your employer's main business (i.e., what the employer makes or does), please indicate the single category that best fits the employer's main business. If the employer has more than one type of business, please answer for the type of work primarily performed at the location where you work.

  • Agriculture, forestry or fishing

  • Biotechnology

  • Construction or mining

  • Education

  • Finance, insurance, or real estate services

  • Health services

  • Information technology or computer services

  • Other services (e.g., social, legal, business)

  • Manufacturing

  • Public administration/government

  • Research (please specify)

  • Transportation services, utilities, or communications

  • Wholesale or retail trade

  • Other (please specify)



X

Position/Job Title (Broad category)



X

Position/Job Title (Specific category)



X

Is job STEM related —choose one

  • Closely related

  • Somewhat related

  • Not related



X

Is your employer an educational institution —choose one

  • Yes

  • No



X

Type of Educational Institution—choose one

  • Preschool, elementary, or middle school system

  • Secondary school system

  • Two-year college, community college, technical institute

  • Four-year college or university, other than a medical school

  • Medical school (including university-affiliated hospital or medical center

  • University-affiliated research institute

  • Other (please specify)



X

What is your faculty rank—choose one

  • Professor

  • Associate professor

  • Assistant professor

  • Instructor

  • Lecturer

  • Adjunct Faculty

  • Other (please specify)

  • Not applicable at the institution

  • Not applicable for my position



X

What is your tenure status—choose one

  • Tenured

  • On tenure track but not tenured

  • Not on tenure track

  • Not applicable: no tenure system at this institution

  • Not applicable: no tenure system for my position



X

How were the responses to the questions on this survey obtained —please choose one

  • Institutional Records

  • Telephone Interviews

  • Exit Interviews

  • Web surveys

  • Email

  • Paper surveys

  • Other (please specify)


X



LSAMP-BD: Number of Respondents, Frequency of Response, and Annual Hour Burden


The estimated average number of annual respondents is 50, with an estimated annual response burden of 3,600 hours. The Web-based data collection is an annual activity of the LSAMP-BD initiative. There are approximately 50 participating institutions. New institutions participating in the LSAMP-BD initiative will be added to the program over the next three years. New institutions are selected to participate in the initiative at approximately the same rate as institutions leave the initiative as their funding expires. The respondents are BD data coordinators. The estimated annual hour burden per respondent was determined by taking the average number of data respondents for each participating BD institution from the previous collection cycles and the actual reported response burden for the BD and peer student data, based on a question in the Web-based data collection system asking how long it takes data respondents to complete the instrument.


The burden estimate is outlined below:


Respondent

Type

Estimated Average Annual No. of

Respondents

Estimated Average Annual Burden Hours Per Respondent

Estimated Annual Burden Hour Total

BD data coordinators

50

72

3,600

Total

50


3,600



LSAMP-BD: Hour Burden Estimates by Each Form and Aggregate Hour Burdens


There is only one form. This form accounts for the entire annual response burden of 3,600 hours. The annual burden by form was calculated as follows:



Form Type

Respondent Type

No. of Respondents

Burden Hours Per Respondent

Total Burden Hours

BD data collection form

BD data coordinators

50

72

3,600

Total

 

50


3,600



LSAMP-BD: Estimates of Annualized Cost to Respondents for the Hour Burdens


The overall annualized cost to the respondents is estimated to be $147,600. The following table shows the annualized estimate of cost to data coordinator respondents, who are generally university professors. This estimated hourly rate is based on a report from the American Association of University Professors, “Annual Report on the Economic Status of the Profession, 2011-12,” Academe, March–April 2012, Survey Report Table 4. According to this report, the average salary of an associate professor across all types of doctoral-granting institutions (public, private-independent, religiously affiliated) was $86,319. When divided by the number of standard annual work hours (2,080), this calculates to approximately $41 per hour.


Respondent
Type

No. of Respondents

Burden Hours Per Respondent

Average Hourly Rate

Estimated Annual Cost

BD data coordinators

50

72

$41

$147,600

Total

50



$147,600



LSAMP-BD: Estimates of Costs to the Federal Government


Computing the annualized cost to NSF for the LSAMP BD data collection was done by taking the budgets for three years and calculating the costs for each of the following operational activities involved in producing, maintaining, and conducting the LSAMP BD data collection:



Operational Activities

Cost Over Three Years

System Development (includes initial development of the database and Web-based application, and later changes requested by the program, e.g., increased reporting tools, additional validations)

$202,737

System Maintenance, Updates, and Technical Support (system requires updates each year before opening the collection; maintenance is required to keep the system current with technology, e.g., database servers, operating systems)

$98,476

Data Collection Opening and Support (e.g., online and telephone support to respondents and contacting respondents to encourage completion of the questions), Reporting (as defined by HRD), and Followup Activities (e.g., providing data to other consultants)

$127,475

Three-Year Total for All Operational Activities

$428,688



The annualized cost was computed as one-third of the total three-year costs; thus, the annualized cost to NSF for the LSAMP BD data collection is $142,896.



LSAMP-BD: Questions


BASELINE DATA

Student Name (First, MI, Last)

Previous Name (BD students only)

LSAMP Institution the student was enrolled in (BD students only)

Bachelor’s Degree-awarding Institution (peer comparison students only)

LSAMP Alliance (to which the above LSAMP institution belongs) (BD students only)

Social Security Number (not required)

Student ID at the Institution (requested/optional)

Gender

  • Male

  • Female

  • Not reported

Ethnicity

  • Not Hispanic or Latino

  • Hispanic or Latino

  • Not reported

Race (choose one or more)

  • American Indian or Alaska Native

  • Asian

  • Black or African American

  • Native Hawaiian or Other Pacific Islander

  • White

  • Not reported

Disability

Yes (check yes if any of the following apply):

  • Deaf or serious difficulty hearing

  • Blind or serious difficulty seeing even when wearing glasses

  • Serious difficulty walking or climbing stairs

  • Other serious disability related to a physical, mental, or emotional condition

No

Do not wish to provide

Citizenship—choose one:

  • U.S. Citizen/U.S. National

  • U.S. Permanent Resident/Green Card holder

  • Other (please specify)

Date of bachelor's degree

Month

Year

Undergraduate Major (choose one or more)

  • Agricultural Science

  • Chemistry

  • Computer Science

  • Engineering

  • Environmental Science

  • Geosciences

  • Life/Biological Sciences

  • Mathematics

  • Physics/Astronomy

  • Other (please specify)

Undergraduate GPA

Undergraduate GPA Scale

4 point scale

5 point scale

LSAMP Level I or II Status: (BD students only)

GRE Scores

Verbal Reasoning

Quantitative Reasoning

Analytical Writing

Research experience during the undergraduate program-choose one

  • Yes

  • No

GRE Scores

Verbal Reasoning

Quantitative Reasoning

Analytical Writing


Please mark the checkbox if this student did not take the GRE

Date entered the STEM Graduate Program

Month Year

Date began receiving BD funding (BD students only)

Month Year

Date entered current graduate program (peer comparison students only)

Month Year

Did this student complete any graduate work before receiving LSAMP BD funding (BD students only)

  • Yes

  • No

Did this student complete any graduate work before entering the current program (peer comparison students only)

  • Yes

  • No

Broad Field Area

Field

Degree —Choose Degree

  • No specific degree or certificate

  • Post baccalaureate Certificate

  • Masters (including MBA)

  • Post Masters Certificate

  • Doctorate (Ph.D., D.S.C., D.Sc., Ed.D.)

  • Other professional degree (J.D., L.L.B., Th.D., M.D, DDS. etc.)

  • Other (please specify)

Date degree awarded

Month Year

If no prior graduate degrees please provide the number of graduate credits completed prior to receiving LSAMP BD funding (BD students only)

If no prior graduate degrees please provide the number of graduate credits completed prior to entering the current graduate program (peer comparison students only)

Teaching assistantship awarded prior to receiving LSAMP BD funding (BD students only)

  • Yes

  • No

Teaching assistantship awarded prior to entering the current graduate program (peer comparison students only)

  • Yes

  • No

Research assistantship awarded prior to receiving LSAMP BD funding (BD students only)

  • Yes

  • No

Research assistantship awarded prior to entering the current graduate program (peer comparison students only)

  • Yes

  • No

ANNUAL DATA

As an undergraduate, did this student participate in LSAMP activities (peer comparison students only)

  • Yes

  • No

LSAMP Level I or II Status (peer comparison students only)

Graduate Program

Intended Broad Major Area

Intended Major

Intended Degree (choose one or more)

  • No specific degree or certificate

  • Post baccalaureate Certificate

  • Masters (including MBA)

  • Post Masters Certificate

  • Doctorate (Ph.D., D.S.C., D.Sc., Ed.D.)

  • Other professional degree (J.D., L.L.B., Th.D., M.D, D.D.S., etc.)

  • Other (please specify)

From which of these sources did this student receive financial support during the current reporting period (BD students only)

NSF LSAMP BD Fellowship

Yes/No

Amount

NSF other grant/fellow

Yes/No

Program Name

Amount

Institution attending

Yes/No

Type of support

Government (federal/state/local)

Yes/No

Type of support

Private funding

Yes/No

Type of support

Other sources (please specify)

Yes/No

Amount

No financial support received

From which of these sources did this student receive financial support during the current reporting period (peer comparison students only)

NSF grant/fellow

Yes/No

Program Name

Other sources (please specify)

Yes/No

No financial support received

From which of these sources did this student receive financial support to pursue graduate studies (i.e., participate in the graduate program listed in the baseline data form) at your institution at any time BEFORE this reporting period (peer comparison students only)

NSF grant/fellow

Yes/No

Program Name

Other sources (please specify)

Yes/No

No financial support received

LSAMP-BD Disbursement Method —choose one (BD students only)

Monthly

Quarterly

By Semester

Yearly

Is the LSAMP-BD stipend or payment based on academic performance —choose one (BD students only)

Yes

No

Did the LSAMP BD funding end for this student during the current Reporting period—choose one: (BD students only)

Yes

No

If yes, please provide the date funding ended:

Month Year

Number of graduate courses credits completed during the current reporting period

Teaching assistantship awarded during the current reporting period

  • Yes

  • No

  • Not Applicable

Research Assistantship awarded during the current reporting period

  • Yes

  • No

  • Not Applicable

Year entered Ph.D. track - (completed 2 years of graduate coursework, equivalent to MA or MS and entered 3rd year of graduate coursework, i.e. post MS and into Ph.D. track):

  • Year:

  • Not entered to Ph.D. track

Thesis Proposal - Date Approved:

Month Year

Not applicable; thesis proposal is not required

Master’s Degree - Date Awarded:

Month Year

Ph.D. Qualifying Examinations - Date passed:

Month Year

Ph.D. Candidacy - Date attained:

Month Year

Dissertation Defense - Date passed:

Month Year

Doctoral Dissertation - Date Approved:

Month Year

Doctoral Degree - Date Awarded:

Month Year

Doctoral Dissertation Abstract

Did the student receive post-LSAMP BD funding to continue graduate studies during the current reporting period (BD students only)—choose one:

  • Yes

  • No


If yes, please provide funding source —choose one:

  • Institution attending

  • Government fellowship: federal/state/local

  • Private fellowship

Did the student leave without completing the program during the current reporting period:

  • Yes

  • No

If yes, please provide the date the student left the program:

Month Year

If he or she left, was it to continue Ph.D. elsewhere?

  • Yes

  • No

  • Don’t know

If he or she left to continue Ph.D. elsewhere, please provide the transfer date:

Month Year

Transfer institution name:


Graduate program at transfer institution:


Intended broad major area at transfer institution:


Intended major at transfer institution:


Intended degree at transfer institution:

  • No specific degree or certificate

  • Post baccalaureate Certificate

  • Masters (including MBA)

  • Post Masters Certificate

  • Doctorate (Ph.D., D.S.C., D.Sc., Ed.D.)

  • Other professional degree (J.D., L.L.B., Th.D., M.D, DDS. etc.)

  • Other (please specify)

Current status at transfer institution:

  • Not yet graduated, but pursuing a doctorate

  • Graduated with a doctorate

Date graduated from transfer institution:

Month Year

  • Dropped out

Date dropped out from transfer institution:

Month Year

  • Other (please specify)

If the student transferred, how were the responses to the transfer questions obtained?(choose one)

  • Institutional Records

  • Telephone Interviews

  • Exit Interviews

  • Web surveys

  • Email

  • Paper surveys

  • Other (please specify)

Please provide the permanent contact information for this student.

Student’s email address

Student’s personal email address

Address

City

State

Zip Code

Country

Phone

Ext.

Name and address (U.S. postal and e-mail) of a person likely to know how to reach this student after he or she graduates

Name

Relationship to this student

Email address

Address

City

State

Zip Code

Country

Phone

Ext.

FOLLOWUP DATA

You indicated that you left the BD program. Did you return to complete your graduate studies? (BD students only)

  • Yes

  • No

You indicated that you left the institution. Did you return to complete your graduate studies? (peer comparison students only)

  • Yes

  • No

When did you return to continue your graduate studies?

Month Year

If you returned to continue your graduate studies, in which program did you enroll? (choose one or more)

  • Post baccalaureate Certificate

  • Masters (including MBA)

  • Post Masters Certificate

  • Doctorate (Ph.D., D.S.C., D.Sc., Ed.D.)

  • Other professional degree (J.D., L.L.B., Th.D., M.D, D.D.S., etc.)

  • Other (please specify)

Graduate program

Intended broad major area

Intended major

Did you return to [student’s original institution name]?

  • Yes

  • No

If No, please provide the name of the institution in which you enrolled:

Please mark the checkbox if no followup data are available for this individual

Did you receive financial support for your M.S./Ph.D. from the following sources? (BD students only)

NSF LSAMP BD Fellowship

Yes/No

Amount

NSF other grant/fellow

Yes/No

Program Name

Amount

Institution attending

Yes/No

Type of support

Government (federal/state/local)

Yes/No

Type of support

Private funding

Yes/No

Type of support

Other sources (please specify)

Yes/No

Amount

No financial support received

Have you received a post doctorate appointment —choose one

Yes

No


If yes, please complete the following items

Date: Month Year

Institution

Department

Field

Are you currently employed —choose one

  • Yes

  • No

When did you begin this job?

Month Year

Is this job full-time —choose one

  • Yes

  • No

Which of the following categories best describes your employer for this job? (choose one or more)

  • A private, for-profit company, business or individual, paying your wages, salary or commissions

  • A Private not-for-profit, tax-exempt or charitable organization

  • Self-employment in own not Incorporated business, professional practice, or farm

  • Self-employment in own incorporated business, professional practice, or farm

  • Local government (e.g., city, county)

  • State government

  • U.S. military service, active duty, or commissioned corps (e.g., USPHS, NOAA)

  • U.S. Government as a civilian employee

  • Other (please specify)

Regarding your employer's main business (i.e., what the employer makes or does), please indicate the single category that best fits the employer's main business. If the employer has more than one type of business, please answer for the type of work primarily performed at the location where you work.

  • Agriculture, forestry or fishing

  • Biotechnology

  • Construction or mining

  • Education

  • Finance, insurance, or real estate services

  • Health services

  • Information technology or computer services

  • Other services (e.g., social, legal, business)

  • Manufacturing

  • Public administration/government

  • Research (please specify)

  • Transportation services, utilities, or communications

  • Wholesale or retail trade

  • Other (please specify)

Position/Job Title (Broad category)

Position/Job Title (Specific category)

Is job STEM related —choose one

  • Closely related

  • Somewhat related

  • Not related

Is your employer an educational institution —choose one

  • Yes

  • No

Type of Educational Institution—choose one

  • Preschool, elementary, or middle school system

  • Secondary school system

  • Two-year college, community college, technical institute

  • Four-year college or university, other than a medical school

  • Medical school (including university-affiliated hospital or medical center

  • University-affiliated research institute

  • Other (please specify)

What is your faculty rank—choose one

  • Professor

  • Associate professor

  • Assistant professor

  • Instructor

  • Lecturer

  • Adjunct Faculty

  • Other (please specify)

  • Not applicable at the institution

  • Not applicable for my position

What is your tenure status—choose one

  • Tenured

  • On tenure track but not tenured

  • Not on tenure track

  • Not applicable: no tenure system at this institution

  • Not applicable: no tenure system for my position

How were the responses to the questions on this survey obtained —please choose one

  • Institutional Records

  • Telephone Interviews

  • Exit Interviews

  • Web surveys

  • Email

  • Paper surveys

  • Other (please specify)



1 Elements of these characteristics include: Name, address, date of birth, gender, ethnicity, race, disability status, class, major, grade point average, yearly fellowship or stipend amount, or project role.

2 Elements of these characteristics include: Sources and amount of funds, fellowships, scholarships, traineeships, partnerships, training, and research methods.

3 Elements of these characteristics include: Research findings, publications, presentations, degrees granted, and educational materials.

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File Typeapplication/msword
File TitleCommon
AuthorLarry Suter
Last Modified By21773
File Modified2012-12-20
File Created2012-12-20

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