Health Services Research and Development Service Career Development Awardee ANNUAL PROGRESS REPORT
TO BE COMPLETED BY THE AWARDEE
DATE COMPLETED
Response should only include updates, changes and activities since the last report. If additional space is needed, continue onto a separate sheet. Attach reprints (if available) of any publications listed. (Please type or print.)
AWARDEE NAME, DEGREES (Print) LOCATION OF PRIMARY OFFICE AND WORK SITE ROUTING SYMBOL
VA TITLE
VA MEDICAL CENTER (City,
State)
ACADEMIC RANK, DEPARTMENT AND AFFILIATION
E-MAIL ADDRESS
TELEPHONE NUMBER
FAX NUMBER
1. SPECIFY ANY CHANGES TO MENTORING, RESEARCH OR CAREER PLANS, INTEREST OR FOCUS SINCE LAST REPORT.
2. LIST ALL NON-RESEARCH ACTIVITIES FOLLOW ED BY PER CENT OF AW ARDEES TIM E COM M ITM ENT TO EACH
Non-Research Role or Activity
A B
%Time
C D
Non-Research Role or Activity
%Time
3. TRAINING SINCE LAST REPORT (formal courses, seminars, data sessions, lab meetings, journal clubs, lecture series, etc.)
Training Received
A B C
Time Period
D E F
Training Received
Time Period
4. PARTICIPATION IN NATIONAL OR INTERNATIONAL SCIENTIFIC MEETINGS
Meeting
A B
Date
C D
Meeting
Date
5. PUBLISHING EFFORT SINCE LAST REPORT, LIST ARTICLES SUBMITTED (attach extra page if necessary), IN-PRESS, OR PUBLISHED
Name of Journal
A B C D E F
Peer Review Y Y Y Y Y Y N N N N N N
1st or 2nd Author? Y Y Y Y Y Y N N N N N N
Topic of Article
Publication Date or Status
6. SPECIAL ACHIEVEMENTS OR RECOGNITION SINCE LAST REPORT
Please refer to the Health Services Research and Development Service Capacity Building Handbook, for a complete description of the Career Development Program and instructions for preparing annual reports.
VA FORM JAN 2002
10-1314
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7. NEW PROJECTS AND PROPOSALS SINCE LAST REPORT (Attach completed VA Forms 10-1313-7 and 10-1313-8)
Project Number
A
Role
Source
Budget
Status
B
C
D
E
F 8. PRESENTATIONS AND INVITED LECTURES SINCE LAST REPORT
Description
A
Occasion
Location
Date
B
C
D
E
F 9 . NAM ES OF M ENTORS AND DESCRIPTION OF LEVEL OF INTERACTIONS WITH AWARDEE (%
time, days/week, days/month, etc.)
Primary Mentor
Secondary Mentor
Tertiary Mentor
10. SIGNATURE(Signature
of Awardee)
DATE
11. NAME AND SIGNATURE OF AWARDEE' S ACOS FOR RD (I
have reviewed the awardees progress and found it satisfactory.)
DATE
12. COMMENTS (Awardee or ACOS for RD)
VA FORM JAN 2002
10-1314
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