Download:
pdf |
pdfOMB #0925-0747
EXP. 11/2019
Attachment 17:
NRMN Annual
Follow-up 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.
Because of your involvement with NRMN programs, you have been selected to be a part of the
Enhance Diversity Study, a national study on experiences and career choices of researchers
and scientists. The National Research Mentoring Networks (NRMN) is part of this study,
through the Diversity Program Consortium, a major national initiative funded by the National
Institutes of Health. This effort is seeking to understand what programs and strategies can
benefit those interested in biomedical, behavioral, clinical, and social science fields.
The Coordination and Evaluation Center at the University of California, Los Angeles, serves as
the coordinating center for this national effort and is in charge of 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.
NRMN has provided the CEC at UCLA your name and contact information because you have
participated in activities that are part of the NIH Diversity Program Consortium’s work. Only with
the continued participation and support from participants such as yourself will we be able to
determine the value of the various programs offered to help students and faculty succeed.
All of the information you provide will be protected and secured to the extent permitted by law.
In this survey, we will gain an understanding of your professional activities during this past year,
including any mentoring/coaching practices, research, scholarly productivity, and other
academic activities. You will have the option to upload a document that includes information
about publications or grants (such as a resume or CV) instead of entering this information
directly for each publication or grant in the survey.
Note: The system will log you out if it has been idle for 20 minutes. Responses are
automatically saved as you navigate from page to page.
Version: 2/8/2019
Page 2 of 32
NRMN Activity
1. According to our records, you participated in the following NRMN programs:
Please describe below any other NRMN activities or programs in which you have
participated:
_JNRMNPGM______________________________________________________
2. JPGCON Are you still connected with any of the people (colleagues or mentors/coaches)
you met through the program(s) listed above? (eg. in communication with colleagues/mentors,
working on projects together with colleagues/mentors, or otherwise collaborating with a
colleague/mentor).
No
Yes
Mentoring Activities and Experiences
Now we would like to ask about your mentoring experiences.
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 a level similar to you (a “peer”). It
can also be someone who serves as an academic or professional “coach.”
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 established responsibilities and perhaps
arranged by your institution) or informal (with someone you have sought out for support).
3. JMNTR Do you consider yourself a mentor or coach?
No
Yes
4. JMNTE Do you consider yourself a mentee or trainee?
No
Yes
Version: 2/8/2019
Page 3 of 32
Now we would like to get information about your current position.
5. What is your current primary position? (Please indicate all that apply)
JCURWK Working (including paid/unpaid internships and significant volunteer
positions)
JCURRT Retired
JCURUN Unemployed, looking for work
JCURO1 Otherwise not in labor force
JCURO2 Other (specify): __JCUROX_______________
6. JSCH Have you been enrolled in school at any time during the past 12 months?
No
Yes and I am still enrolled
Yes, but I am not still enrolled
7. JPRGCM During the past 12 months, did you complete any certificate program?
Definition in rollover “Certificate programs are those that require completion of multiple
units or sessions over extended months or years, but do not end in a degree. Do not
include one-time workshops.”
No
Yes
8. JPRAPP During the past 12 months, 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
9. JSCHLR During the past 12 months, did you receive any scholarships or grants for education
expenses that you do not need to repay?
No
Yes
10. JEDEBT Do you have any education debt?
No
Yes
Version: 2/8/2019
Page 4 of 32
11. To help us be able to track your accomplishments, please provide information about a
number of professional identifiers that you may have:
a. JORCID ORCID _________________
JNOORC I do not have or use
b. JERAID NIH eRA Commons ID ___________________
JNOERA I do not have one
c. JLNKID LinkedIn ID _______________________
JNOLNK I do not have or use
d. My NCBI (PubMed or SciEnv) Publications list (URL):
I do not have or use
e. Any other public listing with your updated publications
Site name (e.g. ResearchGate, Academia.edu, etc.)_____________
ID ______________
I do not have or use one
12. JGRNT 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) in the past 12
months?
No
Yes
13. JPBPRV Have you had publications accepted, in-press, or published in the past 12 months?
This may include peer-reviewed abstracts included in conference proceedings.
No
Yes
14. JPBOT 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
Version: 2/8/2019
Page 5 of 32
15. JCONF Have you presented at a scientific conference in the past 12 months (including
posters)?
No
Yes
16. Have you had any of the following technology transfer activities completed in the past 12
months (select all that apply)?
JTTRIP Issued patents
JTTRLI Completed licenses
JTTRDA Drug, device, or diagnostic approvals
JTTROT Result of basic research commercialized in other ways
JTTRNO I did not have any technology transfer activity
Version: 2/8/2019
Page 6 of 32
17. JAWARD During the past 12 months, were you formally recognized, honored, or awarded in
recognition of your teaching, research, or other professional activity?
☐No (skip to question #18)
☐Yes
a. For what were you recognized? (Choose all that apply.)
☐EAWART Teaching
☐EAWARR Research
☐EAWARO Other professional activity
18. JORGOF Are you a member of a scientific or professional organization?
No (skip to question #19)
Yes
JORGOX If yes, have you held office in any professional organization in the past 12
months? If you provided this information already on your CV, just enter “CV”:
______________________________________________________________________
19. JSRVFD Have you provided service to any federal agencies (e.g. reviewer for
NIH/NSF/CDC or similar proposals, member of federal agency advisory council, etc.) in the past
12 months?
No (skip to question #20)
Yes
JSRVFX If yes, please list any service to federal agencies you have performed in the
past 12 months (e.g. reviewer for NIH/NSF/CDC or similar proposals, member of
federal agency advisory council, etc.): If you provided this information already on
your CV, just enter “CV”:
______________________________________________________________________
20. JSRVOT Have you provided service to any non-federal agencies such as state agencies or
foundations in the past 12 months?
No (skip to question #21)
Yes
JSRVOX If yes, please list any service to non-federal agencies you have performed
in the past 12 months: If you provided this information already on your CV, just enter
“CV”:
______________________________________________________________________
2/8/2019
Page 7 of 32
21. Indicate to what extent the following statements are true of you:
Strongly
Disagree
Disagree
Neutral
Agree
Strongly
Agree
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
a.
JSPOCM I have a
strong sense of belonging to the
community of scientists
b.
JSPOTM I derive great
personal satisfaction from
working on a team that is doing
important research
c.
JSPOTK I have come to
think of myself as a ‘scientist’
a.
JSPOBL I feel like I
belong in the field of science
I choose
not to
answer
22. Indicate to what extent you are confident that you can complete the following tasks:
a. JSPTSK Use technical
science skills (use of tools,
instruments, and/or
techniques)
b. JSPTRQ Generate a
research question to answer
c. JSPTCD Figure out what
data/observations to collect
and how to collect them
d. JSPTER Create
explanations for the result of
the study
e. JSPTRP Use scientific
literature and/or reports to
guide research
f. JSPTDT Develop theories
(integrate and coordinate
results from multiple studies)
2/8/2019
Not at all
confident
A little
confident
Somewhat
Confident
Very
Confident
Absolutely
Confident
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Page 8 of 32
I choose
not to
answer
23. We will be asking questions about the details of publications and grants. Some
people prefer to upload a document (like a CV or list of publications) rather than enter
the information in the survey. If you have such a document, you may upload it here.
I do not want to upload my CV.
2/8/2019
Page 9 of 32
If #3=YES (IS A MENTOR):
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 a level similar to you (a “peer”). It
can also be someone who serves as an academic or professional “coach.”
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 established responsibilities and perhaps
arranged by your institution) or informal (with someone you have sought out for support).
24. JMTREV Have you ever regularly mentored students, post-docs or fellows, junior
researchers, junior faculty, or peers on biomedical career and/or research issues?
No (skip to question #27)
Yes
25. JMTRYR How many years of experience do you have as a mentor on biomedical career
and/or research issues?
1-5 years
6-10 years
11-20 years
21 or more years
I do not have any experience
26. On average, how many different people have you mentored in the past 12 months? (Enter 0
if you do not mentor anyone in a category.)
a.
b.
c.
d.
e.
f.
JMTRST Undergraduate Students: _____
JMTRPB Post-baccalaureate Students: ______
JMTRGS Graduate Students: _____
JMTRPD Post-docs: _____
JMTRJR Faculty: _____
JMTRNO Others: _____
27. JMTRUR NIH has identified groups of mentees or trainees from the following racial and
ethnic groups as underrepresented in the scientific work force: Blacks or African Americans,
Hispanics or Latinos, American Indians or Alaska Natives, Native Hawaiians and other
Pacific Islanders). Approximately how many of your current mentees or trainees are from
these underrepresented groups? ______
2/8/2019
Page 10 of 32
28. JMTRUD Approximately how many of your mentees or trainees are individuals with
disabilities, first generation college students, or those from a low socioeconomic
background? _________
29. How often do you assist any of your mentees with each of these activities?
Never
Rarely
Sometimes
JMTRGR Grant writing and/or
seeking funding for research
JMTRRS Research skills (e.g.,
statistics or instrumentation,
writing for publication, general
advice/supervision in a lab or
project)
JMTRED Educational choices and
strategies (e.g., guidance in
selecting coursework, other
educational opportunities)
JMTRCR Career planning (e.g.,
giving advice, helping network,
linking to opportunities)
JMTRPS Psycho-social support
(e.g., listening to personal
concerns, work-life balance,
diversity issues)
JMTRHO Other (specify)
2/8/2019
Often
Page 11 of 32
30. JMRQUA How would you rate the overall quality of the mentoring you are providing your
mentees?
Very low
Average
1
2
3
4
Very High
5
6
7
31. JMRRST Overall, how satisfied are you with your mentoring/coaching/training
relationships?
Not at all
1
Moderately
2
3
4
Completely
5
6
7
32. JMREXP To what extent do you feel that you are meeting your mentees' expectations?
Not at all
1
Moderately
2
3
4
Completely
5
6
7
33. JMTNOM
We would like to understand more about your mentoring relationship. For the two mentees
with whom you work most closely on research who are from under-represented groups,
please use the following private weblink to provide their names and emails. If you do not
have any mentees who are from under-represented groups, please indicate the two
mentees with whom you work most closely on research.…..
Weblink will not allow anyone to view their names or email addresses. The information will
be used to email a request to these mentees to complete a brief survey regarding their
mentored experience. [Insert a link to a PDF with the survey here.]
Mentees’ names and emails are only available to our research office if the mentees 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. [Weblink for mentor to provide up to 2 mentee names and emails]
2/8/2019
Page 12 of 32
34. Keeping in mind your role as a mentor or coach within a research context, please indicate
how skilled you feel in each mentoring component listed below. Use a scale from 1 to 7 where 1
= “Not at all skilled” and 7 = “Extremely skilled.” If you cannot comment, indicate N/A (not
applicable) in the last column.
Not at
all
skilled
a. JSLSTN Active listening
b. JSFDBK Providing constructive
feedback
c. JSTRST Establishing a relationship
based on trust
d. JSSTYL Identifying and
accommodating different
communication styles
e. JSIMPR Employing strategies to
improve communication with mentees
f. JSOMTR Coordinating effectively
with your mentees' other mentors
g. JSSEXP Working with mentees to
set clear expectations of the
mentoring relationship
h. JSAEXP Aligning your expectations
with your mentees'
i. JSIEXP Considering how personal
and professional differences may
impact expectations
j. JSSGOA Working with mentees to
set research goals
k. JSDGOA Helping mentees develop
strategies to meet goals
l. JSELVL Accurately estimating your
mentees' level of scientific knowledge
m. JSEABI Accurately estimating your
mentees' ability to conduct research
n. JSENHN Employing strategies to
enhance your mentees' knowledge
and abilities
o. JSMOTV Motivating your mentees
p. JSBULD Building mentees'
confidence
q. JSSTMU Stimulating your mentees'
creativity
2/8/2019
Moderately
skilled
Extremely
skilled
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
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
Page 13 of 32
r. JSACKN Acknowledging your
mentees' professional contributions
s. JSINDP Negotiating a path to
professional independence with your
mentees
t. JSBIAS Taking into account the
biases and prejudices you bring to the
mentor/mentee relationship
u. JSDIFF Working effectively with
mentees whose personal background
is different from your own (age, race,
gender, class, region, culture, religion,
family composition etc.)
v. JSNTWK Helping your mentees
network effectively
w. JSCGOA Helping your mentees
set career goals
x. JSBLNC Helping your mentees
balance work with their personal life
y. JSROLE Understanding your
impact as a role model
z. JSRESC Helping your mentees
acquire resources (e.g. grants, etc.)
2/8/2019
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
Page 14 of 32
35. For the next set of questions, please indicate how frequently each of the following has
occurred in your research mentoring relationships during the past 12 months, including any
current research mentoring relationships.
a. JCRROP I created
opportunities for my mentees to
bring up issues of race/ethnicity
as they arose.
b. JCRREXI encouraged
mentees to think about how the
research relates to their own
lived experience.
c. JCRRUN I was willing to
discuss race and ethnicity with
my mentees, even if it made
me uncomfortable.
d. JCRRDF I reflected upon
how the research experience
might differ for mentees from
different racial/ethnic groups.
e. JCRRRE I raised the topic
of race/ethnicity in my research
mentoring relationships when it
was relevant.
f. JCRRST I implemented
specific strategies to address
racial/ethnic diversity in my
research mentoring
relationships.
g. JCRRRM I approached the
topic of race/ethnicity with my
mentee(s) in a respectful
manner.
I
2/8/2019
Never
Rarely
Sometimes
Frequently
All of the
time
1
2
3
4
5
I choose
not to
answer
9
1
2
3
4
5
9
1
2
3
4
5
9
1
2
3
4
5
9
1
2
3
4
5
9
1
2
3
4
5
9
1
2
3
4
5
9
Page 15 of 32
F PARTICIPANT WENT THROUGH GUIDED VIRTUAL MENTORING/MyMentor:
36. a. JGVMNP How many of the prompts did you complete?
None
Some
Most
All
b. JGVMCM Are you still mentoring any of the individuals you were matched with?
Yes
No (skip to question # 37)
c. Which of the following do you help your MyMentor (or Guided Virtual Mentoring)
mentee(s) with? (Choose all that apply)
☐JMTRGR Grant writing and/or seeking funding for research
☐JMTRRS Research skills (e.g., statistics or instrumentation, writing for
publication, general advice/supervision in a lab or project)
☐JMTRED Educational choices and strategies (e.g., guidance in selecting
coursework, other educational opportunities)
☐JMTRCR Career planning (e.g., giving advice, helping network, linking to
opportunities)
☐JMTRPS Psycho-social support (e.g., listening to personal concerns, work-life
balance, diversity issues)
2/8/2019
Page 16 of 32
If #4=MENTEE, CONTINUE. OTHERWISE SKIP TO #:46
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 a level similar to you (a “peer”). It
can also be someone who serves as an academic or professional “coach.”
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 established responsibilities and perhaps
arranged by your institution) or informal (with someone you have sought out for support).
37. JMTECS Do you have faculty members or others who are more senior than you who you
consider mentors?
No (Skip to question #46)
Yes
38. JMTEN How many different mentors do you regularly work with? ______
40. How many mentors help you with (please enter “0” if none of your mentors help you with
that topic):
JMTRGN Grant writing and/or seeking funding for research ___________
JMTRRN Research skills (e.g., statistics or instrumentation, writing for publication, general
advice/supervision in a lab or project) __________________
JMTREN Educational choices and strategies (e.g., guidance in selecting coursework, other
educational opportunities) ____________
JMTRCN Career planning (e.g., giving advice, helping network, linking to opportunities)
JMTRPN Psycho-social support (e.g., motivation, advocacy, listening to personal concerns,
work-life balance, diversity issues) _______________
JMTRON Other ____________
41. JMTELK How did you find these mentors? (Choose all that apply)
They sought me out
I sought them out independently
They were assigned in some other way by my department or campus
I was matched/linked through the National Research Mentoring Network (NRMN)
Matched/linked through some other formal program
Other (specify): ___ JMTECX _____
2/8/2019
Page 17 of 32
42. JMTEOQ How would you rate the overall quality of the mentoring you are receiving from
your mentor?
Very low
Average
Very High
1
2
3
4
5
6
7
43. JMTEOS Overall, how satisfied are you with your mentoring/coaching/training relationship?
Not at all
1
Moderately
2
3
4
Completely
5
6
7
44. JMTEEX To what extent do you feel that your mentor is meeting your expectations?
Not at all
1
Moderately
2
3
4
Completely
5
6
7
45. Please indicate how frequently each of the following has occurred in your research
mentoring relationships during the past 12 months, including any current research mentoring
relationships.
a. JMTMRE My mentor created
opportunities for me to bring up
issues of race/ethnicity as they
arose.
b. JMTMEP My mentor
encouraged me to think about
how the research related to my
own lived experience.
c. JMTDRE My mentor was
willing to discuss race and
ethnicity, even if it may have
been uncomfortable for him/her.
d. JMTRRE My mentor raised
the topic of race/ethnicity in our
research mentoring relationship
when it was relevant.
e. JMTARE My mentor
approached the topic of
race/ethnicity with me in a
respectful manner.
2/8/2019
Never
Rarely
Sometimes Frequently
All of the
time
1
2
3
4
5
I choose
not to
answer
9
1
2
3
4
5
9
1
2
3
4
5
9
1
2
3
4
5
9
1
2
3
4
5
9
Page 18 of 32
IF ITEM #5 = WORKING, COMPLETE ITEM #46
46. a. Earlier you told us you are currently working. Please tell us about your current paid employment
(check all that apply):
JCURFT Full Time
JCURPT Part Time
JCURIN Internship or student placement
JCURSN Seasonal (full-time or part-time)
JCURNP No paid employment (volunteer/unpaid position) (skip to question #46d)
b. JCURPE How is this position related to your education or training?
☐ Directly related to my major or field of study
☐ Indirectly related to my major or field of study
☐ Not at all related to my major or field of study
☐ I choose not to answer
c. JCURPR Is this paid position related to biomedical research?
No
Yes
d. JCURVE Please briefly describe your volunteer / unpaid position:
☐ Directly related to my major or field of study
☐ Indirectly related to my major or field of study
☐ Not at all related to my major or field of study
☐ I choose not to answer
2/8/2019
Page 19 of 32
IF ITEM #6 = YES, COMPLETE ITEMS #47-48
47. COMPLETE IF STILL ENROLLED:
a. JCURCY Expected completion date (year): _____
JCURCD Expected degree: _____
b. JCURSS Status:
Full Time
Part Time
c. JCURSI Institution: _________________
d. JCURSM Major: __
_________________
48. COMPLETE IF NOT STILL ENROLLED
a.
JCURST Please tell us your current status
I graduated from my previous institution (go to question #48b)
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
b. Please indicate the following:
a. JPRGDG Degree / certificate: _________________
b. JPRGMJ Major / area of study: ________________
c. JPRGIN From which institution or school: _________________
d. JPRGDM, JPRGDY Date awarded: MM / YR
2/8/2019
Page 20 of 32
IF ITEM #7 = YES, COMPLETE ITEM #49
49. a. JPRGDG Certificate/the program awards: _________________
b. JPRGMJ Major / area of study: _________________
c. JPRGIN From which institution or school: _________________
d. JPRGDM, JPRGDY Date awarded: MM / YR
2/8/2019
Page 21 of 32
IF ITEM #8 = YES, COMPLETE ITEM #50
50. a. JPRADG Degree / certificate the program awards: ___________
b. JPRAMJ Major / area of study: _________________
c. JPRAIN From which institution or school: _________________
d. JPRADM, JPRADY Date applied: MM / YR
e. JPRAST Status of application:
Accepted and will attend
Accepted and will not attend
Waitlisted
Pending
Not accepted
2/8/2019
Page 22 of 32
IF ITEM #9 = YES, COMPLETE ITEM #51
51. a. JSCHNM Name of scholarship/grant: ______________________________
b. JSCHTO Amount (total value including value of any fee/tuition waivers):
Less than $1,000
$1,000-4,999
$5,000-9,999
$10,000 or more
c. JSCHSM / JSCHSY, JSCHEM / JSCHEY Period of award: MM/YYYY to MM/YYYY
d. JSCHY Was this award based on:
Need
Merit
Need and Merit
Other (specify): ______ JSCHYX __________
2/8/2019
Page 23 of 32
IF ITEM #10 = YES, COMPLETE ITEM #52
52. a. JEDTOT Total amount that you owe:
Less than $5,000
$5,000-9,999
$10,000-19,999
$20,000 or more
I don’t know how much I owe
b. JEDPYT How much you borrowed during the past year:
None
Less than $1,000
$1,000-4,999
$5,000-9,999
$10,000 or more
2/8/2019
Page 24 of 32
IF ITEM #12 = YES, COMPLETE ITEM #53
53. Please complete or update information for each grant or proposal:
NOTE: If this information is already provided on your CV that you uploaded, you do not
complete this item. Please check here if you want us to refer to your CV.
54. a. JGRA Funding Agency Type:
NIH
Other federal (e.g. NSF)
Nonfederal governmental
Nonprofit (e.g. foundations)
For-profit/Industry
Other (specify): ____________
b. [If a=Nonfederal, Nonprofit, For-Profit, Other]
JGRX Agency/Foundation/Company Name: __________________
c. JGRR Role:
Principal Investigator
Co-PI
Investigator
Other (specify): _____________
d. JGRS Submission status:
Submitted (first time for this proposal)
Re-submitted with revisions
Not funded
Funded
e. JGRF [If #a=NIH] Grant funding mechanism:
K (any type)
P (any type)
R01
R03 or R21
Other R series
T (any type)
U (any type)
F32/32
Diversity supplement
SC (SCORE)
Pilot grant
K99/R00
Other (e.g., supplements, etc.) (specify): JGRFX ____________
2/8/2019
Page 25 of 32
IF ITEM #13 = YES, COMPLETE ITEM #55-56
55. NOTE: If this information is already provided on your CV that you uploaded, you do
not complete this item.
If you did not upload your CV at the previous item about grants but have decided you
would like to do so, you will be able to upload at the end of the survey.
Please check here if you want us to refer to your CV.
56. a. JPBTLTitle: __________________
b. JPMID PMID # if available: ________________(if provided, skip to question #38)
c. JPBAU List all Authors (Last FM, comma separated): ______, ______, ______, ______
d. JPBJN Journal Name: __________________
e. JPBYR Year Published (or indicate “in press” or “epub ahead”): ________
f. JPBVL Volume: ______
g. JPBIS Issue: ______
h. JPBPN Page Numbers: ______
i. JPBDO DOI or URL for epubs: ____________________
2/8/2019
Page 26 of 32
IF ITEM #14 = YES, COMPLETE ITEM #57
57. a. JPOTY Publication Type:
Chapter
Book
Other, specify: JPOTX ____________
b. JPOAU List all Authors (Last FM, comma separated): ______, ______, ______, ______
Complete the applicable information below depending on publication type:
c. JPOBT [if Book or Chapter] Book/Anthology Title: __________________
d. JPOER [If Chapter] Book Editors: __________________
e. JPOYR Year Published: ______
f. JPOED [If Book or Chapter] Edition: ______
g. JPOPB [If Book or Chapter] Publisher: ________________
h. JPOCY City: ________________
i. JPOST State: __________
j. JPOPG [If Book or Chapter] Page Numbers: ______
k. JPODO DOI or URL for epubs: ____________________
2/8/2019
Page 27 of 32
ALL RESPONDENTS COMPLETE NEXT SET OF ITEMS (58-67)
58. Which categories describe you? Select all boxes that apply. Note, you may report more than
one group.?
DWHITE White – For example, German, Irish, English, Italian, Polish, French, etc.
DHISP Hispanic, Latino/a, or Spanish Origin – For example, Mexican or Mexican
American, Puerto Rican, Dominican, Salvadoran, Peruvian, Mestizo, Chicano, etc.
DBLACK Black or African American – For example, Jamaican, Haitian, Nigerian,
Ethiopian, Somali, Creole, Caribbean, etc.
DAMRIN American Indian or Alaska Native – For example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Quechua, Native Village of Barrow Inupiat Traditional Government,
Nome Eskimo Community, etc.
DASNIN Asian – For example, Chinese, Filipino, Asian Indian, Vietnamese, Korean,
Japanese, etc.
DNHAWA Native Hawaiian or Other Pacific Islander – For example, Native Hawaiian,
Samoan, Guamanian or Chamorro, Tongan, Fijian, Marshallese, etc.
DMENA Middle Eastern or North African – For example, Lebanese, Iranian,
Egyptian, Syrian, Moroccan, Algerian, Armenian, etc.
DROTH Some other race, ethnicity, or origin (Specify: DROTX _________________)
Detailed follow up Race/Ethnicity items:
58a. Select all boxes that apply and/or enter details in the space below.
WHITE
German
Irish
English
Italian
Polish
French
Enter, for example, Scottish, Norwegian, Dutch, etc.
___________________________________________________
58b. Select all boxes that apply and/or enter details in the space below.
HISPANIC, LATINO, OR SPANISH
Mexican or Mexican American
Puerto Rican
Cuban
Salvadoran
Dominican
Columbian
Enter, for example, Guatemalan, Spaniard, Ecuadorian, Chicano, etc.
___________________________________________________
2/8/2019
Page 28 of 32
58c. Select all boxes that apply and/or enter details in the space below.
BLACK OR AFRICAN AMERICAN
African American
Jamaican
Haitian
Nigerian
Ethiopian
Somali
Enter, for example, Ghanaian, South African, Barbadian, etc.
___________________________________________________
58d. Enter details in the space below.
AMERICAN INDIAN
Enter, for example, Navajo Nation, Blackfeet Tribe, Muscogee (Creek) Nation, etc.
_____________________________________________________________________
ALASKA NATIVE
Enter, for example, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community,
Orutsararmiut Native Council, etc.
______________________________________________________________________________
CENTRAL OR SOUTH AMERICAN INDIAN
Enter, for example, Mayan, Aztec, Taino, etc.
_______________________________________________________________________________
58e. Select all boxes that apply and/or enter details in the space below.
ASIAN
Chinese
Filipino
Asian Indian
Vietnamese
Korean
Japanese
Enter, for example, Pakistani, Cambodian, Uyghurs, etc.
___________________________________________________
2/8/2019
Page 29 of 32
58f. Select all boxes that apply and/or enter details in the space below.
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
Native Hawaiian
Samoan
Chamorro
Tongan
Fijian
Marshallese
Enter, for example, Palauan, Tahitian, Chuukese, etc.
___________________________________________________
58g. Select all boxes that apply and/or enter details in the space below.
MIDDLE EASTERN OR NORTH AFRICAN
Lebanese
Iranian
Egyptian
Syrian
Moroccan
Enter, for example, Israeli, Iraqi, Tunisian, Armenian, etc.
___________________________________________________
59. DGEND What is your current gender identity?
Man
Woman
Trans man
Trans woman
Gender queer/Gender non-conforming
Different identity
I choose not to answer
2/8/2019
Page 30 of 32
60. EMARITAL Are you currently:
(1) Single
(2) In a civil union
(3) In a domestic partnership
(4) Married
(5) Unmarried, living with partner
(6) Separated
(7) Divorced
(8) Widowed
61. How many children do you have in the following age ranges?
0 1
2
3
4+
ENCHILD01 Under 18 years old
0 1
2
3
4
ENCHILD02 18 years or older
0 1
2
3
4
2/8/2019
Page 31 of 32
Keeping in Touch with You
Your input to the Enhance Diversity Study is extremely valuable and important.
So, we want to be sure we can stay in touch with you over the next few years to ask for your
input on an annual basis.
Please provide the following information to help us be sure we can reach you:
62. Please provide any additional email addresses that you use other than the one we
reached you at for this survey:
a. DEMAIL1 _________________________
b. DEMAIL2___________________________
c. DEMAIL3___________________________
63. Please provide one or more phone numbers where you can usually be reached:
a.
DPHONE1 (__ __ __) __ __ __ - __ __ __ __
b.
DPHONE2 (__ __ __) __ __ __ - __ __ __ __
64. DFCBK Please provide your Facebook name:
_________________________
65. Please provide the name and contact information for a family member or close friend who
will likely know how to reach you in the future:
DCTNAM Name: ___________________
DCTEML Email: _____________________
DCTPHN Phone: (__ __ __) __ __ __ - __ __ __ __
66. DPADDR What is your permanent address?
____________________________________________________________
67. DCADDR What is your current address (if different from your permanent address)?
____________________________________________________________
2/8/2019
Page 32 of 32
| File Type | application/pdf |
| Author | Vardanyan, Tatevik T. |
| File Modified | 2019-11-20 |
| File Created | 2019-11-02 |