Survey Center (RISR) : Intake Form

Intake Form

Please fill out as much as possible. You may write "Note sure" or "Don't Know" if uncertain.

Contact Information

Please make sure you have filled in all required fields with valid information.

Name of Project:

PI Name:

PI Email:

IRB Approved:

Yes No

Funding Stage:

(need to write grant/grant submitted/grand received?)

Timeline (approximate dates) Information

Please make sure you have filled in all required fields with valid information.

Pilot Study:

Data Collection Starts:

Data Collection Ends:

Completion of Statistical Analysis:

Conference Date:

Project Information

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Status of Survey Instrument:

(already written/used in research?)

Data Collection Method:

(paper/Qualtrics/other)

Data Storage Plan:

(per IRB proposal)

Add additional information that you would like us to know about your project: