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* 1. Full Name (First Middle Last)

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* 2. Current Institution

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* 3. Email address

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* 4. Which of the following best describes your current practice setting (check all that apply):

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* 5. What is your specialty?

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* 6. What is the name of your current practice or institution?

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* 7. What year did you complete your training (gastroenterology, surgical, other)?

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* 8. Please indicate if any of the following apply to you now or at any time SINCE receiving your FIRST ASGE grant (check all that apply):

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* 9. What percentage of your professional effort involves the following (numbers should add up to 100%):

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* 10. PRIOR TO receiving your FIRST ASGE grant, which of the following grants have you been awarded as Principal Investigator (check all that apply)?

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* 11. Prior to receiving your FIRST ASGE grant, please check which of the following degrees applied to you (check all that apply):

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* 12. Did your ASGE grant(s) directly lead to any original publications (please do not include abstracts)?

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* 13. How many original, peer-reviewed, scientific publications did you publish PRIOR TO your first ASGE grant (up to, and including the year of the first award)? (Please limit your count to original research papers and exclude editorials, abstracts, review articles, invited commentaries, etc.)

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* 14. How many original, peer-reviewed, scientific publications have you published SINCE the year of your first ASGE grant (don’t count the year that the grant was awarded)? (Please limit your count to original research papers and exclude editorials, abstracts, review articles, invited commentaries, etc.)

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* 15. Since receipt of your first ASGE grant, have you, as a Principal Investigator, received Federal research funding (e.g. NIH, VA, CDC, DOD, CIHR)?

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* 16. Since receipt of your first ASGE grant, have you, as a Principal Investigator, received other extramural non-industry research funding (e.g. Crohn’s and Colitis Foundation, American Cancer Society, AGA, ACG)?

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* 17. Since receipt of your first ASGE grant, have you, as a Principal Investigator, received industry research funding?

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* 18. Did the ASGE Research Grant result in new collaborations?

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* 19. Are there any take home messages from your grant that would be important to share with industry partners who provide funds to the ASGE Foundation?

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* 20. Which of the following statements best describes the impact the ASGE grant has had on your professional career:

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* 21. Please tell us your reason for choosing the above item. Please provide as much detail as possible.

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* 22. Any other comments? Please consider the following questions when making a response:
a. Besides papers, what impact has the project had on the practice of GI endoscopy?
b. What subsequent research was influenced by the funded project?
c. Were there positive career impacts on you and/or others as a result of the grant?
d. In general, can you speak to a “magnifier effect” of the grant?
e. Did the grant open any doors for you in your career?

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