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HwUaGwLTPIcIjuo2fpPyJfxBjXQSDjVzuiukCpUtqA5szuk4n3FLJYHhcjqxn5aUJBL7Dx6ZoJiwU8cYtZ

Engagement, Recruitment, and Retention Certificate Program Nomination Form

Thank you for your interest in nominating your employee for the program. The person nominating an employee from your CRU should be the direct supervisor of the employee or RPM/ARPM of the CRU.

Please read the following before beginning the nomination form for the Recruitment, Engagement, and Retention Certification program.

The facilitators of this program are collecting data to evaluate the effectiveness of this certificate program. The employee will be asked to submit a self-assessment before and after the program.

We will not share personal information we collect about participant competency with anyone outside the program leadership team. Participation is optional and will not affect education, employment, or future status at Duke.

If you have questions about program participation or assessment completion, please contact Jamie at Jamie.roberts@duke.edu or Jessica Cranfill at Jessica.Cranfill@duke.edu.

Please fill out the nomination form completely.

Please select Cohort for Nomination

* must provide value

Nominee First Name

* must provide value

Nominee Last Name

* must provide value

Nominee Unique ID

* must provide value

Nominee NetID

* must provide value

Nominee Email Address

* must provide value

Nominee Phone Number

Nominee Job Title and Tier

* must provide value

Enter "Other" Job Title

Which part of Duke does the nominee work in?

* must provide value

School of Medicine (SOM)

School of Nursing (SON)

Campus

Other

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Enter "Other" part of Duke

What Clinical Research Unit (CRU) or Oversight Organization (OO) does the nominee work in?

* must provide value

What Department or Division does the nominee work in?

* must provide value

What is your relationship to the nominee?

* must provide value

Direct Supervisor

RPM of CRU or OO

Your Name

* must provide value

Your Email

* must provide value

How long has the nominee worked in Clinical Research?

* must provide value

Brand new to clinical research

< 1 year

1 year - 3 years

>3 years - 5 years

>5 years - 7 years

>7 years or more

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How long has the nominee worked at Duke?

* must provide value

Brand new to Duke

< 1 year

1 year - 3 years

>3 years - 5 years

>5 years - 7 years

>7 years or more

reset

What percentage of this person's effort do you estimate is related to participant recruitment activities?

* must provide value

1-10%

11 - 20%

21-30%

31-40%

41-50%

51-60%

61 - 70%

71 - 80%

81 - 90%

91 - 100%

reset

What percentage of this person's effort do you estimate is related to retention activities?

* must provide value

1-10%

11 - 20%

21-30%

31-40%

41-50%

51-60%

61 - 70%

71 - 80%

81 - 90%

91 - 100%

reset

Why are you interested in having this employee go through the certificate program?

* must provide value

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If accepted, will you be able to allow this employee to attend all 6 core classes and at least 3 electives over the 6 month cohort-period?

Note: attendance is important since space in the cohort is limited and we may not be able to accept all nominees. If employees miss class they will be asked to complete a homework assignment equivalent to attending the class.

* must provide value

Yes, I'll allow it.

RPM email

Please include any comments or concerns here.

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.