DEPARTMENT OF VETERANS AFFAIRS

RESEARCH AND DEVELOPMENT INFORMATION SYSTEM

INVESTIGATOR DATA

1\. NAME:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 2.
DEGREE:\_\_\_\_\_\_\_\_\_ 3. SSN:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4\. VA TITLE:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
PHONE #:\_\_\_\_\_\_\_\_\_\_\_ MAIL CODE:\_\_\_\_\_\_\_

5\. UNIVERSITY APPOINTMENT:

a.  Academic Rank \_\_\_\_\_
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> *(Enter code from Table 5a) Code (Enter name of Academic Rank; if code
> = 00, skip to Item 5 )*

b\. University administrative Title \_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*(Enter code from Table 5b) Code (If code = 99, enter name of University
Administrative Title)*

c\. University Department
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*(Enter name)*

d.  Department Section/Division
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> *(If applicable, enter name of section or Division)*

e\. University Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*(Enter name of University)*

6.  DIPLOMATE STATUS, BOARD CERTIFIED Yes No Not Applicable

> *(See instructions, item 6)*

7\. SPECIALTY: \_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*(Enter code from Table 7)* *Code (If code 99, enter name of Specialty*

8\. SUBSPECIALTY: \_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*(Enter code from Table 8) Code (If code = 99, enter name of
Subspecialty*

9\. VA EMPLOYMENT: \[ \] FULL-TIME

*(Check one)*

\[ \] PART-TIME:\_\_\_HR/WK *(If Part-time, enter hr/wk.)*

\[ \] CONSULTANT \[ \] CONTRACT \[ \] WOC

10\. VA SALARY SOURCE: \[ \] VA FUNDS OTHER THAN R&D

*(Check one)*

\[ \] MEDICAL RESEARCH (PROGRAM 821) FUNDS

\[ \] HSR&D (PROGRAM 824) FUNDS

\[ \] REHAB R&D (PROGRAM 822) FUNDS

\[ \] COOPERATIVE STUDIES (PROGRAM 825) FUNDS

\[ \] NOT SALARIED BY VA

11\. VA HOSPITAL SERVICE: \_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*(Enter code from Table 11) Code (If code = 99, enter name of VA
Hospital Service)*

12\. VA HOSPITAL SECTION
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*(If applicable, enter name of Hospital Section)*

13. PRIMARY RESEARCH INTEREST \_\_\_\_\_\_\_
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> *(Enter code from Table 13-14)* *Code (If code = 99, enter name of
> Primary Research interest)*

14. SECONDARY RESEARCH INTEREST\_\_\_\_\_\_
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> *(Enter code from Table 13-14) Code (If code = 99, enter name of
> Secondary Research Interest)*

INVESTIGATOR'S SIGNATURE:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ DATE:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_

VA FORM 10-5368

**Jan 1997 PART 1 -- PAGE 18**

PERSONAL DATA ON VA INVESTIGATORS

Research and Development has a continuing commitment to monitoring the
operation of its review and award processes to detect -- and deal
appropriately with -- any instances of real or apparent inequities with
respect to sex, race, or ethnicity.

To provide Research and Development with the information it needs for
this important task and for responding to Congress about the sex, race
and ethnic composition of VA investigators, please complete the form
below and return it to the Research Office (151).

This form will not be a part of any review process. Data will be
confidential. All analyses conducted on the data will report aggregate
statistical findings only and will not identify individuals.

If you decline to provide this information, it will in no way affect
your status as a VA investigator.

Your cooperation will be appreciated.

SEX

Female Male

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

RACE AND/OR ETHNIC ORIGIN *(Check one)*

Note: The category that most closely reflects the individual's
recognition in the community should be used for purposes of reporting
mixed racial and/or ethnic origins.

*American Indian or Alaskan Native.* A person having origins in any of
the original peoples

> of North America, and who maintains a cultural identification through
> tribal affiliation or
>
> community recognition.

*Asian or Pacific Islander.* A person having origins in any of the
original peoples of the Far

East, Southeast Asia, the Indian subcontinent, or the Pacific Islands.
This area includes, for

Example, China, India, Japan, Korea, the Philippine Islands, and Samoa.

*Black, not of Hispanic origin.* A person having origins in any of the
black racial groups of Africa.

> *Hispanic.* A person of Mexican, Puerto Rican, Cuban, Central of South
> American, or other Spanish culture or origin, regardless of race.
>
> *White, not of Hispanic origin.* A person having origins in any of the
> original peoples of Europe, North Africa, or the Middle East.
>
> Check here if you do not wish to provide some or all of the above
> information.

Name
(print)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature Date

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[CODES AND INSTRUCTIONS FOR INVESTIGATOR DATA SHEET (VA FORM 10-5368;
PAGE 18)]{.underline}**

**5a. ACADEMIC RANK:** The default Academic Rank for each Series is
shown. If actual rank is different, or code is 06, enter name.

01 = Instructor Series 03 = Assistant Professor Series 05 = Professor
Series 00 =None

02 = Lecturer Series 04 = Associate Professor Series 06 =
Resident/Fellow/Trainee/Other

**5b. UNIVERSITY ADMINISTRATIVE TITLE:** The default University
Administrative Title for each Series is shown.

If actual title is different, or code is 99, enter name.

01 = Department chair Series 02 = Division Chief Series 03 = Dean Series
00 =None

**6.** **DIPLOMATE STATUS, BOARD CERTIFIED:** Physicians, Dentists,
Psychologists -- Check

YES or NO. Non-physicians -- Check NOT APPLICABLE.

**7.** **SPECIALTY:** Select Board or area of training or expertise. If
99 is selected, enter name in space provided.

01 = Allergy & Immunology 70 = Emergency Medicine 34 = Nursing 51 =
Physiology

66 = Anatomic Pathology 16 = Endodontics 35 = Obstetrics/Gynecology 52 =
Plastic Surgery

67 = Anatomic & Clinical Pathology 17 = Engineering 71 = Occupational
Medicine 53 = Preventive Medicine

02 = Anatomy 18 = Epidemiology 36 = Oncology 54 = Public Health

03 = Anesthesiology 19 = Family Practice 37 = Operations Research 55 =
Prosthodontics

04 = Anthropology 20 = General Practice 38 = Ophthalmology 56 =
Psychiatry

05 = Audio logy 21 = Genetics 39 = Optometry 57 = Psychology

06 = Biochemistry 22 = Geriatrics 40 = Oral Pathology 73 = Radiation
Oncology

07 = Bioengineering 23 = Health Care Administration 41 = Oral Surgery 58
= Radiology

08 = Biology 24 = Health Economics 42 = Orthopedic Surgery 59 =
Rehabilitative Medicine

09 = Biophysics 25 = Histology 43 = Osteopathy 60 = Social Work

10 = Biostatistics 26 = Immunology 44 = Otolaryngology 61 = Sociology

11 = Chemistry 27 = Internal Medicine 45 = Pathology 62 = Speech
Pathology

68 = Clinical Pathology 28 = Mathematics 46 = Pediatrics 63 = Surgery
(General)

12 = Colon & Rectal Surgery 29 = Medical Illustration 47 = Periodontics
64 = Thoracic Surgery

13 = Dentistry (General) 30 = Microbiology 48 = Pharmacology 65 =
Urology

14 = Dermatology 31 = Neurological Surgery 49 = Pharmacy 99 = Other
(Specify)

69 = Diagnostic Radiology 32 = Neurology 72 = Physical Medicine &
Rehabilitation

15 = Dietetics 33 = Nuclear Medicine 50 = Physics

**8.** **SUBSPECIALTY:** Physicians -- Enter code for ONE Board or area
of training, or 00 (not applicable). If 99 is selected, enter name.
Non-physicians -- enter 00.

29 = Addiction Psychiatry 08 = Endocrinology 39 = Medical Microbiology
23 = Physiological Psychology

01 = Administrative Medicine 09 = Experimental Psychology 40 = Medical
Oncology 24 = Public Health

03 = Allergy 10 = Forensic Pathology 41 = Medical Toxicology 25 =
Pulmonary Disease

30 = Cardiac Electrophysiology 35 = Forensic Psychiatry 16 = Metabolism
26 = Rheumatology

04 = Cardiovascular Disease 11 = Gastroenterology 17 = Nephrology 44 =
Sports Medicine

05 = Child Psychiatry 12 = General Preventive Medicine 18 =
Neuropathology 27 = Therapeutic Medicine

31 = Clinical & Laboratory Immunology 36 = Geriatric Medicine 19 =
Neuropsychology 28 = Therapeutic Radiology

32 = Clinical Neurophysiology 37 = Geriatric Psychiatry 20 =
Occupational Medicine 45 = Vascular Surgery

06 = Clinical Psychology 38 = Hand Surgery 42 = Nuclear Radiology 99 =
Other (Specify)

33 = Critical Care Medicine 13 = Hematology 43 = Pain Management 00 =
Not Applicable

34 = Dermatopathology 14 = Immunology 21 = Pediatric Allergy

07 = Diagnostic Radiology 15 = Infectious Disease 22 = Pediatric
Cardiology

**11.** **HOSPITAL SERVICE:** Select code for the hospital service with
which the investigator is identified and/or from which salary is paid.
If salaried from VA research funds, enter code 09, 13, 27, or 41.

24 = Pulmonary Disease

01 = Administration 08 = Education 16 = Nuclear Medicine 25 = Radiology

02 = Ambulatory Care 36 = Extended Care 17 = Nursing 26 = Rehabilitative
Medicine

34 = Anesthesiology 09 = HSR&D (Program 824) 38 = Ophthalmology 27 =
Rehabilitation R&D (Program (822)

03 = Audio logy & Speech Pathology 37 = Geriatrics 39 = Otolaryngology
28 = Recreation

04 = Chaplain 10 = GRECC 18 = Outpatient Clinic 30 = Social Work

41 = Cooperative Studies (Program (825) 11 = Intermediate Care 19 =
Pathology 31 = Spinal Cord Injury

05 = Dental 12 = Laboratory 20 = Pharmacy 32 = Surgery

35 = Dermatology 13 = Medical Research (Prog 821) 21 = Prosthetics 40 =
Urology

06 = Dietetics 14 = Medical 22 = Psychiatry 33 = Voluntary

07 = Domiciliary 15 = Neurology 23 = Psychology 99 = Other (Specify)

**13 and 14. PRIMARY and SECONDARY RESEARCH INTERESTS:** Select codes
that best define general areas of primary and secondary interests. Do
NOT use 00 for primary research interest.

01 =

01 = A 01 = Aging 11 = Drug Dependence 52 = Neuropsychology 29 =
Radiology 02 = 02 = Alcoholism 45 = Emergency Medicine 21 = Nuclear
Medicine & Radiation 61 = Rehabilitation

38 = Ambulatory Care 12 = Endocrinology & Metabolism 22 = Nutrition 30 =
Rehabilitation Medicine

03 = Anesthesiology 46 = Epidemiology 23 = Nursing 31 = Respiration &
Pulmonary Disease

04 = Audio logy & Speech Pathology 13 = Gastroenterology 24 = Oral
Biology 32 = Rheumatology

05 = Basic Science 47 = Geriatrics 25 = Oncology 33 = Social Work

06 = Behavioral Science 48 = Health Care 53 = Ophthalmology 62 = Spinal
Cord Injuries

07 = Biochemistry 49 = Health care 26 = Orthopedic Surgery 34 = Surgery

39 = Bioengineering 50 = Health Services 27 = Pathology 63 = Urology

40 = Biomechanics 14 = Hematology 54 = Pharmacology 64 = Vascular
Surgery

08 = Cardiovascular Disorders 15 = Immunology 55 = Pharmacy 35 =
Veterinary Medicine

41 = Clinical Epidemiology 16 = Infectious Diseases 28 = Podiatry 36 =
Virology

09 = Clinical Pharmacology 51 = Medical Education 56 = Post Traumatic
Stress Disorders 37 = Vision

42 = Computer Science 17 = Mental Health 57 = Preventive Medicine 99 =
Other (Specify)

43 = Critical Care 18 = Molecular Biology 58 = Prostatic Disease 00 =
None

44 = Dental Implants 19 = Nephrology 59 = Prosthetics

10 = Dermatology 20 = Neurology & Neurobiology 60 = Psychiatry