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1 Default Question Block The RWJF Board of Trustees is interested and engaged in the success of our scholars and alumni. The RWJF Human Capital team would like to be able to speak about our scholars and alumni in a meaningful, data driven way. Therefore, the team is asking all scholar programs to survey alumni annually and collect information for the previous calendar year. This information will be shared with senior management. The Foundation is committed to measuring the impact of our programs; so gaining information on our alumni activities is an important part of reporting. After the survey results are compiled, an aggregate report will be provided to all alumni, as well as the Foundation. 1) What is your last name, first name? 2) What years were you in and what program site did you belong to in the RWJF Clinical Scholars program? 3) Currently in what institution(s) do you work and what is your title(s)? 4) Please provide a preferred for contact purposes. 1 of 6 3/20/13 2:53 PM

2 5) Please list any awards or recognition you received from in calendar year 2012: (a) a national professional organization and or (b) any other organization 6) Please list any national or state commissions or boards you have served on in calendar year 2012: 2 of 6 3/20/13 2:53 PM

3 7) Please identify the number of articles you have published and or number of editorial boards you have served on for the following journals in calendar year 2012; you may choose to include up to six additional journals in the free response section at the bottom of this table. Number of Publications Number of Editorial Boards American Journal of Managed Care American Journal of Preventive Medicine American Journal of Public Health American Political Science Review American Psychologist American Sociological Review Annals of Behavioral Medicine Health Affairs Health Services Research JAMA Journal of Economic Literature Journal of Health Policy and Law Medical Care Milbank Quarterly Nature NEJM Research in Nursing and Health Science Journal Name 1 Journal Name 2 Journal Name 3 Journal Name 4 Journal Name 5 Journal Name 6 3 of 6 3/20/13 2:53 PM

4 8) If you included publication information in question seven, please provide any abstracts and citations from the journals you identified in the text field below. 9) If you are at an academic institution, did you receive tenure in calendar year 2012? Yes No Not Applicable 10) Did you receive a new grant from the federal government (any agency) as a PI or Co-PI during calendar year 2012? Yes No If yes, please provide funding source, grant title, and amount of award. The Robert Wood Johnson Foundation values differences among individuals across multiple dimensions including, but not limited to, race, ethnicity, age, gender, sexual orientation, physical ability, religion, and socioeconomic status. 11) Please indicate the gender for which you self-identify. Male Female 4 of 6 3/20/13 2:53 PM

5 12) Of the following, please indicate the option for which you self-identify. Hispanic or Latino Not Hispanic or Latino 13) Please indicate the race/ethnicity for which you self identify. American Indian or Alaskan Native Asian Black or African American Native Hawaiian or other Pacific Islander Other Race White 14) Of the categories below, please identify all those with which you self-identify. First generation college graduate Earned a degree at a historically black college or university Earned a degree at a Hispanic serving institution Earned a degree at a Tribal college or university Began higher education at a community college Grew up in a low income community None of the above Please list any underrepresented groups not mentioned above with which you self-identify 15) When you were selected as a scholar for the RWJF Clinical Scholars program, were you a first time health researcher because of that grant? Yes No 5 of 6 3/20/13 2:53 PM

6 16) While the information provided to the Foundation annually will be in the aggregate (total number of alumni publications for example) the NPO would like your permission to include your name and associated accomplishments in a future newsletter or website posting. Any demographic information you provide will remain internal to the NPO and will not be shared. Please indicate by selecting the option below, if you would like to opt-out of this: Yes, I would like to opt-out No, you may use my information in marketing materials 17) Please provide us with any other additional information you deem important: 6 of 6 3/20/13 2:53 PM

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