VCOM Institutional Policy and Procedure Manual

Edward Via College of Osteopathic Medicine Survey Request Form

Please make all survey requests are made at least one month prior to the desired implementation date. Requestors are responsible for seeking approval to conduct a survey from the required parties. Furthermore, all surveys must adhere to guidelines set forth by the Family Educational Rights and Privacy Act (FERPA), the VCOM Institutional Review Board (IRB), and any other relevant College, state or federal guidelines/regulations. If your survey contains any portion that has been copyrighted or is the intellectual property of another party, your survey may be subject to approval by said party. In such instances, documentation showing copyright approval must be obtained and submitted with this form. Please provide as much information as possible about your proposed survey. Submit the completed form to the Office of the President and Provost. __________________________________________________________________________________________ Personal Information

Name: Position: Campus: Phone:

Email Address: ……………………………………………………………………………………………………………………… Survey Information

Title of Survey:

Description of the survey project, including the purpose and intended use of results: