Clinical Researcher Tracking Survey

Researcher Name: _______________________________________________

Address: ______________________________________________________

Phone: ________________________________________________________

Email: _________________________________________________________

Fax: __________________________________________________________



ECRIP Project Title: _____________________________________________

Name of Institution: _____________________________________________



Sponsor/Mentor: ________________________________________________

Address: _______________________________________________________

Phone: ________________________________________________________

Email: _________________________________________________________

Fax: __________________________________________________________



Background Information

Please check mark by the response, or fill in where appropriate

Gender:

____ Male

____ Female

Age:

____ 24-29

____ 30-34

____ 35-39

____ 40-44

____ 45-49

____ 50-54

____ 55 and up

Citizenship Status:

____ U.S. Citizen

____ U.S. National

____ Permanent Resident

Race/Ethnicity (optional):

____ Native American/Alaskan Native

____ Asian or Pacific Islander

____ Black/African American (Not Hispanic)

____ Hispanic/Latino

____ White (Not Hispanic/Latino)

____ Other ___________________________________________________

Type of Medical Education:

____ Allopathic (M.D.)

____ Osteopathic (D.O.)

Medical School:

____ New York State (If so, please indicate below)

____ Other U.S. (specify) __________________________________________

____ Other Country (specify) _______________________________________

If in NYS, specify:

____ Albany Medical College

____ Albert Einstein College of Medicine

____ Columbia University College of Physicians and Surgeons

____ Mt. Sinai School of Medicine

____ New York College of Osteopathic Medicine

____ New York Medical College(Valhalla)

____ New York University

____ SUNY at Brooklyn

____ SUNY at Buffalo

____ SUNY at Stony Brook

____ SUNY at Syracuse

____ University of Rochester

____ Weill Medical College of Cornell University

Please indicate the researcher´s current and past employment (academia, private industry, research, medical practice, or other), along with dates and job duties

Employment Date From Date To Job Duties
           
           
           
           
           

What is the researcher´s specialty?: _________________________________

Is the researcher board certified in this specialty?: ______________________

Research Status

Is the researcher presently participating in research?:

____ Yes Employer: ________________________ Location (inc. state): ___

____ No

Current Research Activities

What type of research is the researcher actively participating in:

____ Clinical

____ Bench

____ Translational

____ Other (specify) ____________________________________________

Does the researcher have an oversight or mentor position?

____ Yes

____ No

If so, does the researcher mentor:

____ Medical Students

____ Residents

____ Other (please specify) _______________________________________

Please indicate the hours per week and percent of effort spent in the following activities:

Hours Effort
Research      
Patient Care      
Administration      
Teaching      
Other (specify):      

Please list any publications/presentations (since beginning the ECRIP fellowship to present):


Publications:_________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Presentations:______________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Please fill out the chart at the end of the survey regarding research support received.

E-mail:gme@health.state.ny.us

NYS Council on Graduate Medical Education
Corning Tower, Room 1190
Albany, NY 12237
FAX: (518) 486-7854

Research support received:

Funding Entity Project Name Research Role (co-investigator, principal) Field of Study Population (rural, urban, special, other) Amount of Funding Dates
                 
to
                 
to
                 
to
                 
to
                 
to
                 
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