Research Survey Request Form * Note: All fields with an asterisk in their label are required fields. Contact InformationName* First Last Email* Survey Request InformationWhat is the primary aim of your study?*Please report any conflicts of interest with respect to this study.*Name of the Institutional Board granting IRB Approval.* Date of your IRB Approval.* MM slash DD slash YYYY See Submission Instructions below for a list of required attachments.Who is the principal investigator or senior faculty sponsor for this study?* Is this person a member of APOSW?*- Select One -YesNo(i.e. principal investigator or faculty sponsor)What population are you proposing to survey?* Is the survey being administered to other groups outside of APOSW?*- Select One -YesNoWhat is the target sample size for this study?* Briefly describe the study methods.* (e.g. power analysis)Approximately how long does it take to complete the survey?* List any funding for this project.*(Include both internal and external funding sources.)Please provide a timeline for the project.*Note: (Please include the following in your answer, above: 1) How long do you plan to collect data? 2) When are you hoping to have the data collected, analyzed, and ready for dissemination?)Would you consider presenting your findings at a future APOSW conference?*- Select One -YesNoAgreementsPosting Agreement*I understand that if the APOSW Research Committee approves me to invite members of APOSW to participate in this research, this study can be posted to the APOSW-List listserve a maximum of three times within six months of approval. Yes Submission Fee*I further agree to submit a payment of a one-time $50.00 charge for three postings (APOSW members) or a one-time $200.00 charge for three postings (non-APOSW members). Yes Electronic SignatureSignature Name* Please re-enter your name to confirm that this serves as your electronic signature.Date Signed* MM slash DD slash YYYY Submission Instructions Upon submission of this form, you will receive an email confirmation, which will contain instructions for submission of your required attachment documents. Your Research Survey Request cannot be considered until the following required documents have also been received. These include copies of the following: 1) IRB Proposal 2) IRB Approval Letter 3) Final Survey Instrument or link to Online Survey, along with accompanying correspondence. Please submit all required documents in Adobe PDF format. Download, print and save a copy of the Research Survey Request Form Instructions (PDF)PhoneThis field is for validation purposes and should be left unchanged.
