Attachment 14 Build Faculty Annual Followup Survey

OMB #0925-0747
EXP. 11/2019

Attachment 14:
BUILD Faculty Annual Follow-up Survey
(Revised 7.31.17)

OMB #0925-0747
EXP. 11/2019

BUILD Faculty Annual Follow-up Survey
As you may recall, is involved in a large effort funded by the
National Institutes of Health (NIH) to support students and faculty in biomedical, behavioral, clinical, and social science fields. This effort, the NIH Diversity Consortium,
is seeking to understand what programs and strategies can benefit faculty and their
students interested in these careers.
The University of California, Los Angeles (UCLA) is collecting information about these
programs in order to evaluate the extent to which these efforts are successful in improving outcomes for students and faculty. If we can show benefits, this can increase
the likelihood of continuation and expansion of these efforts.
has provided UCLA your name and contact information because
you have previously contributed to this effort by completing the Higher Education
Research Institute (HERI) Faculty Survey offered at your institution this past academic
year. Only with the continued participation and support of faculty such as yourself will
we be able to determine the value of the various programs offered through your institution to help students succeed. All of the information you provide will be protected
and secured to the extent permitted by law.
In this survey, we will ask you about your activities during this past academic year,
including teaching practices, research, scholarly productivity, and mentoring. You will
have the option to upload a document that includes information about publications or
grants (such as a CV) instead of entering this information directly for each publication
or grant in the survey.
Public reporting burden for this collection of information is estimated to average 25
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 (0925-0747). Do not return
the completed form to this address.

OMB #0925-0747
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1. During the 2016-17 academic year or the summer of 2017, have you taken advantage of
any of the following professional development opportunities at this institution?
Yes

No

Not
Eligible

Not
Available

Funded workshops focused on teaching
Funded workshops focused on mentoring
Funded workshops focused on conducting research
Funded workshops focused on NIH funding
Funded workshops focused on other funding
Funded workshops on other career development topics
(e.g., publishing, gaining tenure)
Paid sabbatical leave
Travel funds paid by the institution
Travel funds paid by a grant (e.g. BUILD)
Internal grants for research
Training for administrative leadership
Incentives to develop new courses
Incentives to integrate new technology into your classroom
Incentives to integrate culturally competent practices into
your classroom

2. During the 2016-17 academic year or the summer of 2017, have you engaged in any of
the following activities? (choose all that apply)
Participated in the development of curriculum (enhancing an existing course or creating a new course)
Taught a newly developed course
Participated in the development of supplementary cultural curriculum for students or
faculty (e.g. stereotype threat, cultural assets, cultural competency, etc.)
Taught a newly developed supplemental cultural course for students or faculty

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3. How confident are you that you can do the following
Not at all
Confident

Setting learning goals
Selecting reading materials
Designing assignments
Planning class activities
Using various teaching strategies
Engaging students in learning
Providing students opportunities to practice skills
Promoting student collaboration
Encouraging students to ask questions
Encouraging students to express ideas
Encouraging participation from women
and minorities
Accurately assessing students’ knowledge
Grading assignments using criteria
Providing students constructive suggestions
Providing students with prompt feedback
Fostering students’ independent thinking
Addressing sensitive issues in ways that
help students to deal with them maturely
Fostering students’ confidence in ability to
learn
Providing students an overview of discipline
Demonstrating passion for teaching
Staying current in subject knowledge
Helping students understand the relevance of learning
Enriching teaching with research

Slightly Somewhat
Very
Extremely
Confident Confident Confident Confident

OMB #0925-0747
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Mentoring

This next section concerns your experiences with mentoring in a variety of contexts.
A mentor is someone who provides guidance, assistance, and encouragement on
professional and academic issues. A mentor can be either someone who is more
experienced (or senior) than you or someone who is at an educational or professional level similar to you (a “peer”).
A mentee is someone who receives guidance or assistance from a mentor. A mentee can be someone less experienced (or junior) than you or someone who is your
peer.
A mentoring relationship can be formal (with a set schedule and perhaps arranged by
your institution) or informal.
4. Do you have anyone you currently mentor about academics, career or research?
We are interested in undergraduates, post-bacs or graduate students, post-docs, or
faculty, not primary or secondary school students.
No

Yes

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5. How many different people to you regularly mentor currently? (Enter 0 if you do not
mentor anyone in a category.)
Undergraduate Students:
Post-baccalaureate Students:
Graduate Students:
Post-docs:
Faculty:
Others:
6. Which of the following do you help your mentees with? (choose all that apply)

Research in general (e.g., general advice/supervision in a lab or on a project )
Specialized research issues (e.g., statistics or instrumentation,writing for publication)
Research-related grant writing and funding
Educational choices and strategies (e.g., guidance in selecting coursework, other
educational opportunities)
Career planning (e.g., giving advice, helping network, linking to opportunities)
Personal support (e.g., listening to personal concerns, work-life balance)
Other (specify):
7. How did you first connect with your mentees? (choose all that apply)
I sought them out
They sought you out independently
They were assigned by your department or campus
Through an NRMN mentorship program
Matched/linked through some other formal program
Other (specify):
8. Please tell us how frequently you communicate with your mentees with each of these
approaches:
In-person
Phone/Skype/Zoom
Email/Text
Other

Weekly or
more often

Monthly

Every 2-3
months

A few times
a year

Annually
or less

Never

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9. For the two mentees with whom you work most closely on your research, please use the
following private weblink to provide the name and email for those mentees. Weblink will not
allow anyone to view their names or email addresses. Information will be used to email a
request to these mentees to complete a brief survey regarding their mentored experience.
Mentees’ names and emails are only available to our research office if the mentees elect to
respond to the email request by going to the website and completing the survey. Their information will be deleted from the system after 3 months if they do not respond to the requests
to participate.
10. Please rate how skilled you are in each of the following mentoring areas:

Active listening

Not at all
Skilled
(1)

Providing constructive feedback
Establishing a relationship based on trust
Identifying and accommodating different
communication styles
Employing strategies to improve communication with mentees
Coordinating effectively with your mentees’
other mentor
Working with mentees to set clear expectations of the mentoring relationship
Aligning your expectations with your mentees’
Considering how personal and professional
differences may impact expectations
Working with mentees to set research goals
Helping mentees to develop strategies to
meet goals
Accurately estimating your mentees’ level of
scientific knowledg
Accurately estimating your mentees’ ability
to conduct research
Employing strategies to enhance your mentees’ knowledge and abilities

(2)

Moderately
Skilled
(3)
(4)
(5)

Extremely
Skilled
(6)
(7)
(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

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Not at all
Skilled
(1)

Motivating your mentees
Building mentees’ confidenc
Stimulating your mentees’ creativity
Acknowledging your mentees’ professional
contributions
Negotiating a path to professional independence with your mentees
Taking into account the biases and prejudices you bring to your mentor/mentee relationship
Working effectively with mentees whose personal background is different from your own
(age, race, gender, class, region, culture,
religion, family composition etc.)
Helping your mentees network effectively
Helping your mentees set career goals
Helping your mentees balance work with
their personal life
Understanding your impact as a role model
Helping your mentees acquire resources
(e.g. grants, etc.)

(2)

Moderately
Skilled
(3)
(4)
(5)

Extremely
Skilled
(6)
(7)
(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(n/a)

11. Please indicate your agreement with the following statements:
Strongly
Disagree

It is important to consider the
mentee’s and the mentor’s race/
ethnicity in mentoring relationships
It is important to me to have
others in my research work environment that have a similar racial/ethnic background to mine.

Disagree

Neutral

Agree

Strongly
Agree

N/A

OMB #0925-0747
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Strongly
Disagree

Disagree

Neutral

Agree

Strongly
Agree

N/A

All of the
Time

N/A

Completely
confiden
5

N/A

I am aware of the assumptions
that I have about race/ethnicity

12. Please indicate how frequently you do the following:
Never

Rarely

Sometimes Frequently

I raised the topic of race/ethnicity in my research mentoring relationship when it was relevant.
I asked my mentees how they
were doing in general
13. How confident are you in your ability to
Not at all
confiden
1

2

3

4

address the role of race and
ethnicity in the mentoring relationship
14. How would you rate the overall quality of the mentoring you are providing to your mentees?
Very low
1

2

3

Average
4

5

6

Very High
7

15. To what extent do you think you are meeting your mentee’s expectations?
Not at all
1

2

3

Moderately
4

5

6

Completely
7

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EXP. 11/2019

Receiving Mentoring

Now we would like to ask you about any mentoring that you receive. This first set of items
asks about mentoring you may get from those who are SENIOR to you.
16. Do you have a faculty member or someone else who is more senior than you who
you currently consider a mentor?
No

Yes

17. How many different mentors do you regularly work with?
18. Which of the following does your primary mentor help you with? (choose all that
apply)
Research in general (e.g., general advice/supervision in a lab or on a project )
Specialized research issues (e.g., statistics or instrumentation,writing for publication)
Research-related grant writing and funding
Educational choices and strategies (e.g., guidance in selecting coursework, other
educational opportunities)
Career planning (e.g., giving advice, helping network, linking to opportunities)
Personal support (e.g., listening to personal concerns, work-life balance)
Other (specify):
19. How did you find this mentor
They sought you out
You sought out your mentor independently
They were assigned by your department or campus
Through NRMN
Matched/linked through some other formal program
Other (specify):
20. Please tell us how frequently you communicate with your primary mentor with each
of these approaches:
In-person
Phone/Skype/Zoom
Email/Text
Other

Weekly or
more often

Monthly

Every 2-3
months

A few times
a year

Annually
or less

Never

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EXP. 11/2019

21. How would you rate the overall quality of the mentoring you are receiving?
Very low
1

2

3

Average
4

5

6

Very High
7

22. To what extent are your mentors meeting your expectations?
Not at all
1

2

3

Moderately
4

5

6

Completely
7

23. During the past year, have you engaged in any of the following activities? (Choose
all that apply)
Yes

Participated in a mentor training program, as an attendee (preparation to
mentor)
Participated in a mentee training program, as an attendee (preparation to
be mentored)
Participated in the development of mentoring program curriculum for students or faculty
Led/Taught a mentor training program
Led/Taught a mentee training program
Accessed the National Research Mentoring Network (NRMN)

No

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Research, Grants, and Career Activity

24. We would like to know how confident you are today that you can successfully perform
the tasks listed below. Using a 0-10 scale, indicate your level between No Confidence (0)
and Total Confidence (10) in your current abilities in these general areas of research and
grant writing. Use NA when a task statement does not seem appropriate for your training.
No
Confidence
(0)
(1)

Select a suitable topic
area for study.
Refine a problem so
that it can be investigated.
Develop a logical rationale for a particular
research idea.
Organize your proposed research ideas
in writing.
Articulate a clear purpose for the research.
Place your study in
the context of existing
research and justify
how it contributes to
important questions in
the area.
Relate your specific
questions of interest to
underlying theory.
Convince grant reviewers your proposed
study is worth funding.
Choose an appropriate
research design that
will answer a set of research questions and/
or test a set of hypothesis.

(2)

(3)

(4)

(5)

(6)

(7)

(8)

Total
Confidence
(9)
(10) (n/a)

(0)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(n/a)

(0)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(n/a)

(0)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(n/a)

(0)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(n/a)

(0)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(n/a)

(0)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(n/a)

(0)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(n/a)

(0)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(n/a)

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No
Confidence
(0)
(1)

State the purpose,
strengths, and limitations of each study
design.
Determine the universe, population, and
appropriate sample for
a given study.
Determine an adequate
number of subjects for
your research project.
Select methods of data
collection appropriate
to the study population and variable(s) of
interest.
Determine how each
variable will be measured.
Design the best data
analysis strategy for
your study.
Identify appropriate
funding sources (local,
state, national) to support a study.
Speak with a person
at the funding agency
regarding your project
or project ideas.
Describe a major funding agency’s (e.g., NIH,
foundation) proposal
review and award process.
Write a competitive
grant application.

(2)

(3)

(4)

(5)

(6)

(7)

(8)

Total
Confidence
(9)
(10) (n/a)

(0)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(n/a)

(0)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(n/a)

(0)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(n/a)

(0)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(n/a)

(0)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(n/a)

(0)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(n/a)

(0)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(n/a)

(0)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(n/a)

(0)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(n/a)

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No
Confidence
(0)
(1)
-

(2)

(3)

(4)

(5)

(6)

(7)

(8)

Total
Confidence
(9)
(10) (n/a)

(0)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(n/a)

(0)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(n/a)

(0)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(n/a)

(0)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(n/a)

(0)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(n/a)

(0)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(n/a)

Write-up research fin
ings for publication in a
peer-reviewed journal.
Conduct the appropriate statistical analyses
to answer your research questions.
Summarize research
findings in a traditional
research report.
Summarize and highlight research findings
for publication in a
peer-reviewed journal.
Communicate key
research findings to
a wide audience of
stakeholders.
Submit paper and/or
poster presentations to
conferences related to
your topic area.
Present research
findings at conferences
related to your topic
area.

25. The next set of items ask about grants and publications. If you have a document that
lists these (such as a CV), you can upload that document and skip some of the items below.
Otherwise, we will ask you to provide information about each grant and publication.
Upload now

I do not want to upload now

I do not have a document to upload

OMB #0925-0747
EXP. 11/2019

26. During the past year, have you applied for any grant funding or other financial support
for your research (either as Principal Investigator or as Co-Investigator or other paid position)
No

Yes

27. Please complete or update information for each grant or proposal:
a. Funding Agency Type:
NIH
Other federal (e.g. NSF)
Nonfederal governmental
Nonprofit (e.g. foundations
For-profi
Other (specify):
b. Full grant number if available
c. Agency/Foundation/Company Name:
d. Role:
Principal Investigator
Co-PI
Investigator
Other (specify):
e. Your percent effort:

% or

calendar months

f. Submission status:
Submitted (first time for this proposal
Re-submitted with revisions
NIH Impact score (if applicable):
Not funded
NIH Impact score (if applicable):
Funded
g. Project Title:

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h. Annual direct cost (average across all years):
Less than $50,000
$50,000-$99,000
$100,000-$249,000
$250,000-$499,000
$500,000 or more
i. Start Date (e.g., 07/2015)

/

j. End Date (e.g., 07/2016)

/

k. What was the main purpose of the funding?
Research
Training of others (e.g., students, peers, workforce)
Your career development
Other (specify):

28. Have you conducted research that is not covered by the grants listed above?
No

Yes

a. What type of research was this? (select all that apply)
Literature review, synthesis of existing knowledge, and/or conceptual
Analysis of existing (secondary) data
Analysis of data you collect (primary analysis)
b. What was your role? (select all that apply)
PI/Co-PI or Project Lead
Investigator
Other (specify):

29. The next set of items ask about publications. If you have a list of these and did not
upload already, you can upload it now.
Upload now

I do not want to upload now

I do not have a document to upload

OMB #0925-0747
EXP. 11/2019

30. Do you have any peer-reviewed publications accepted, in-press, or published in the
past year? This may include peer-reviewed abstracts included in conference proceedings.
No

Yes

If yes, please answer the following questions:
a. PMID # if available:
b. List all Authors (Last FM, comma separated):
c.
d.
e.
f.
g.
h.
i.

Title:
Journal Name:
Year Published (or indicate “in press” or “epub ahead”):
Volume:
Issue:
Page Numbers:
DOI or URL for epubs:

31. Are there other scientific publications of yours to add to this list? (e.g. book chapters,
books, reports, non-peer reviewed journal articles, working papers, other)
No

Yes

a. Publication Type:
Chapter
Book
Other (specify):

b. List all Authors (Last FM, comma separated):

OMB #0925-0747
EXP. 11/2019

Complete the applicable information below depending on publication type:
c. Book/Anthology Title:
d. Chapter Title :
e. Editors:
f. Year Published:
g. Edition:
h. Publisher:
i. City:
j. State:
k. Page Numbers:
l. DOI or URL for epubs:

32. Have you presented at a scientific conference in the last year (including posters)
No

Yes

a. Was this a conference publication with: (choose all that apply)
Undergraduate student(s)
Post-baccalaureate student(s)
Graduate student(s)
Post-doctoral scholar(s)
Faculty
33. During the 2016-17 academic year or the summer of 2017, have you participated in
any technology transfer activities (including being named in patents, completed licenses,
and any drug, device, or diagnostic approvals)?
No
Yes
a. Please enter a title and brief description for each Technology Activity:
New patent issued
License completed
Drug, device, or diagnostic received regulatory approval
Result of basic research commercialized
Other (specify):

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34. During the 2016-17 academic year or in the summer of 2017, were you formally recognized, honored, or awarded in recognition of your teaching, research, or other professional
activity?
No
Yes
If yes, please list any honors or awards you received during this time in recognition of your
teaching, research, or other professional activity:

35. During the 2016-17 academic year or in the summer of 2017, did you hold office in any
professional organization?
No

Yes

If yes, please list any offices you held in professional organizations during this time

36. Did you provide service to any federal agencies (e.g. reviewer for NIH/NSF/CDC or
similar proposals, member of federal agency advisory council, etc.) during the 2016-17
academic year or the summer of 2017?
No

Yes

If yes, please list any service to federal agencies you have performed during this time (e.g.
reviewer for NIH/NSF/CDC or similar proposals, member of federal agency advisory council, etc.):

37. Did you provide service to any non-federal agencies such as state agencies or foundations during the 2016-17 academic year or the summer of 2017?
No

Yes

If yes, please list any service to non-federal agencies you have performed during this time:

Faculty Rank and Position

We would like to be sure our information is correct about your current position.

OMB #0925-0747
EXP. 11/2019

38. [For those who took the 2016 survey] Our records indicate you are ______ at
______. Has that changed?
No

Yes

39. What is your current primary position? (Please indicate all that apply)
In school
Working (including internships and significant volunteer positions)
Retired
Unemployed, looking for work
Otherwise not in labor force
Other (specify):
a. Expected completion date for degree program (year):
Expected degree:
b. Status:

Full Time

Part Time

c. Institution:
d. Major:
e. Paid Employment (check all that apply):
Full Time
Part Time
Internship or student placement
Seasonal (full-time or part-time)
Volunteer, unpaid internship, or other unpaid position
Briefly describe your paid position(s):
Position:
Institution or Company:
f. Is this paid position related to research?
No

Yes

g. Is this new job/position considered a promotion or advancement?
No

Yes

OMB #0925-0747
EXP. 11/2019

40. To allow us to follow your professional accomplishments, please provide any of the
following identifiers that you may have
ORCID ID

I do not have one

NIH eRA Commons ID

I do not have one

LinkedIn ID

I do not have one

41. Do you have any of the following disabilities or medical conditions?
Yes

No

Yes

No

Learning disability (dyslexia, etc.)
Attention deficit hyperactivity disorder (ADHD
Autism spectrum/Asperger’s syndrome
Physical disability (speech, sight, mobility, hearing, etc.)
Chronic illness (cancer, diabetes, autoimmune disorders, etc.)
Psychological disorder (depression, etc.)
Other (please specify):

42. Please indicate “Yes” or “No” for each of the following:
Are you deaf or do you have serious difficulty hearing
Are you blind or do you have serious difficulty seeing, even when
wearing glasses?
Because of a physical, mental, or emotional condition, do you
have serious difficulty concentrating, remembering, or making
decisions?
Do you have serious difficulty walking or climbing stairs
Do you have difficulty dressing or bathing
Because of a physical, mental, or emotional condition, do you
have difficulty doing errands alone such as visiting a docto ’s
office or shopping

OMB #0925-0747
EXP. 11/2019

43. Have you been enrolled in school at any time during the past year?
No
Yes and I am still enrolled
Yes, but I am not still enrolled

a. Expected completion date (year):
Expected degree:
b. Status:
Full time
Part time
c. Institution:
d. Major:

e. Please tell us your current status
I graduated from my previous institution
I did not graduate but do have plans to attend school in the next 2 years
I did not graduate and do NOT have plans to attend school in the next 2 years
f. Please indicate the following:
Degree / certificate
Major / area of study:
From which institution or school:
Date awarded

/

OMB #0925-0747
EXP. 11/2019

43. During the past year, did you complete any certificate program?
No

Yes

If yes, please indicate the following:
a. certificate:
b.Major / area of study:
d. From which institution or school:
d. Date awarded

/

44. During the past year, did you apply to any degree or certificate program?
Note: If you completed a program above, please indicate here any other program applications.
No

Yes

If yes, please indicate the following:
a. Degree / certificate the program awards:
b.Major / area of study:
c. From which institution or school:
d. Date awarded

/

e. Status of application:
Accepted and will attend
Accepted and will not attend
Waitlisted
Pending
Not accepted
45. What type of courses do you primarily teach? (Mark one)

Undergraduate courses
Graduate courses
Non-credit courses
I do not teach
46.3. In the past year, have you taught a graduate course?

No
Yes

OMB #0925-0747
EXP. 11/2019

47. In how many of the courses that you teach do you use each of the
following?

All

Most

Some

None

a. Student presentations

4

3

2

1

b. Student evaluations of each
others’ work

4

3

2

1

c. Class discussions

4

3

2

1

d. Cooperative learning (small
groups)

4

3

2

1

e. Experiential learning/Field
studies

4

3

2

1

f.

4

3

2

1

g. Group projects

4

3

2

1

h. Student-selected topics for
course content

4

3

2

1

i.

Reflective writing/journaling

4

3

2

1

j.

Using student inquiry to drive
learning

4

3

2

1

4

3

2

1

Demonstrations

k. Peer-led activities

OMB #0925-0747
EXP. 11/2019

48. Do you have anyone you currently mentor who is at a similar career level
to yours (a peer)?
No
Yes
49. How many different peers do you mentor currently? ____

50. Which of the following do you help your peers with? (choose all that
apply)
Research issues
Social and emotional needs, e.g. sharing concerns about career and
work-life balance
Tangible help, e.g. advice about faculty colleagues and teaching, help
with writing
Networking assistance, e.g. helping you meet other people in your
field
Career planning (e.g. giving advice, helping find opportunities)
Other (specify): _________________

OMB #0925-0747
EXP. 11/2019

51. How did you first connect with these peers? (choose all that apply)
They were assigned by your department or campus
Through a NRMN mentorship program
Matched through some other formal program
They sought you out independently
Other (specify): _________________

52. How do you communicate with your peer mentees?
In-person
Phone/Skype
Email/Text
Other (specify): _____________________

53. On average, how often do you usually communicate with these peers
about their research?
Weekly or more often
Monthly
Several times a year
Annually or less

54. For the two peers whom you mentor most, please use the following
private weblink to provide the name and email for those mentees.
Weblink will not allow anyone to view the name or email address.
Information will be used to email a request to these mentees to complete
a brief survey regarding their mentored experience. Mentee name and
email are only available to our research office if the mentee elects to
respond to the email request by going to the website and completing the
survey. Their information will be deleted from the system after 3 months
if they do not respond to the requests to participate.

OMB #0925-0747
EXP. 11/2019

55. Do you have someone at a similar educational level as you (i.e. a peer)
who you currently consider a mentor?

No
Yes

56. How many different peer mentors do you have? ____

57. Which of the following do your primary peer mentors help you with?
(choose all that apply)

Research issues
Social and emotional needs e.g. sharing concerns about career and
work-life balance
Tangible help (e.g. advice about faculty colleagues and teaching, help
with writing)
Networking assistance ( e.g. helping you meet other people in your
field)
Career planning (e.g. giving advice, helping find opportunities)
Other (specify): _________________
58. How did you find this primary mentor?

They were assigned by your department or campus
Through NRMN
Matched through some other formal program
You sought out your mentor independently
Other (specify): _________________

OMB #0925-0747
EXP. 11/2019

59. How do you usually communicate with your primary peer mentor?
In-person
Phone/Skype
Email/Text
Other (specify): ______________________________________

60. How often do you usually communicate with your primary peer
mentor?
Weekly or more often
Monthly
Several times a year
Annually or less

61. In the past year, to what extent have you:

To A Great
Extent

To Some
Extent

Not at All

a. Engaged in a research project
directed by others

1

2

3

b. Worked with undergraduates
on a research project

1

2

3

c. Worked with graduate
student(s) on a research
project

1

2

3

d. Engaged in your own research
project

1

2

3

e. Engaged undergraduates on
your own research project

1

2

3

1

2

3

1

2

3

f.

Engaged graduate students on
your research project

g. Engaged in public discourse
about your research or field of
study (e.g. blog, media
interviews, op-eds, etc.)

N/A

OMB #0925-0747
EXP. 11/2019

62. Please respond to the following statements about your primary mentee that you
have worked with in the past year.

This is not one
of my
mentoring
objectives

I have considered
how to include
this in my
mentoring

I have tried to do
this in my
mentoring

I have evidence I
have done this
effectively in my
mentoring

a. My mentor gave me an
overview of how my
research fit into an overall
research project.

1

2

3

4

b. My mentor helped me
develop my research
skills.

1

2

3

4

c. My mentor showed
interest in my research
project.

1

2

3

4

d. My mentor was
available to me when I had
problems or questions
about my research.

1

2

3

4

e. My mentor offered
constructive feedback
when necessary.

1

2

3

4

g. My mentor and I
developed a relationship
based on trust.

1

2

3

4

h. My mentor understood
how I learn best.

1

2

3

4

i. My mentor created an
environment that allowed
me to achieve my goals.

1

2

3

4

j. My mentor and I
discussed diversity issues.

1

2

3

4

k. My mentor seemed so
busy that I was afraid to
interrupt him/her.

1

2

3

4

l. My mentor had an
effective mentoring style.

1

2

3

4

m. My mentor acted as a
positive role model.

1

2

3

4

n. My mentor showed
interest in me as a person.

1

2

3

4

o. My mentor expressed
consideration for his/her
cultural background as
well as my own.

1

2

3

4

p. My mentor fostered my
independence.

1

2

3

4

q. My mentor fostered
confidence in my skills.

1

2

3

4

r. My mentor appreciated
my contributions.

1

2

3

4

s. My mentor encouraged
me to be creative.

1

2

3

4

t. My mentor made me
enthusiastic about my
project.

1

2

3

4

u. My mentor helped me
feel curious about my
project.

1

2

3

4

v. My mentor treated me
as a colleague.

1

2

3

4

w. My mentor helped me
decide on a career path.

1

2

3

4

x. My mentor
communicated his/her
expectations of me.

1

2

3

4

y. My mentor respected
my goals.

1

2

3

4

z. My mentor allowed me
to take ownership in my
research.

1

2

3

4

aa. My mentor created an
environment where I felt
safe to make mistakes.

1

2

3

4

bb. My mentor made me
feel included in the lab.

1

2

3

4

cc. My mentor valued and
respected cultural
differences.

1

2

3

4

dd. My mentor regularly
assessed skills and
knowledge that I gained in
the lab

1

2

3

4

OMB #0925-0747
EXP. 11/2019

63. Your base institutional salary reported is based on:
Less than 9 months
9/10 months
11/12 months

64. Are you currently:
Single
In a civil union
In a domestic partnership
Married
Unmarried, living with partner
Separated
Divorced
Widowed
65. How many children do you have in the following age ranges?
Under 18 years old
18 years or older

0

1

2

3

4+