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Survey Request Form
INSTRUCTIONS:
- Complete the form entirely, listing all survey details.
- ATTACH a list of your survey questions (in Word).
- Click the SUBMIT button.
NOTE: *Required fields
REQUESTOR INFORMATION:
Name:
Request Date:
+
E-mail:
Phone # (ext.):
*
Supervisor Name:
*
Supervisor E-mail:
*
Survey Priority:
High (within 2 days)
Medium (within 2 weeks)
Low (within 2 months)
Required Date:
+
SURVEY DETAILS:
Who is your intended audience?
*
What is your survey title?
*
List the survey description, survey introduction, or survey instructions (to the survey participant) below:
*
Survey type (check all boxes that apply):
Fill in the blank
Yes/No
Select from list provided (provide list in the "other" box below)
Rating scale (provide your scale in the "other" box below)
Comment box(es)
Other
Other
Do you want to include a demographics section to your survey?
*
Yes
No
Please list the "required" demographics in the "Other" box below.
If yes, please check all of the demographics you would like to include:
Campus
Age (range)
Sex
Job classification
Location (residence town)
Participant Name
Participant ID
Other
Other
Please list your survey rules below:
Survey open date:
*
+
Survey open time:
*
Survey close date:
*
+
Survey close time:
*
Do you want the participant to only answer once?
Yes
No
Insert Survey Questions and Answers here:
*
SURVEY RESULTS:
How do you want to receive your results?
File Type (check all that apply):
PDF
PPT
XLS
CSV
Comment:
Qustions about this form? Contact the Help Desk.