Institutional Survey Request Form

Requestor Information

Requestor Name/Title:

Department:

Supervisor's Name:

E-mail Address:

Phone/Extension Number:

Please describe the purpose of your survey and how the information will be used (be specific):

Survey Population

Select your survey population (you may select more than one):

Students:
Undergraduate Master's Credential Other Post Baccalaureate
Faculty:
Tenure Track Lecturers
Staff:
Full Time Part Time

Specifics about your population (i.e. First-time Freshman who are registered as undeclared). Please be as specific as you can:

Note: Depending on the population chosen above, the IRP Director may require a random sample size be used. Sampling is a common, statistically valid survey method, allowing multiple surveys to go to similar populations at the same time without affecting response rates.

Survey Administration Type:

Online Paper Other

If other, please describe:

Timeline for Survey

Proposed date(s) on which survey will be administered:

Anticipated close date of survey:

Survey results needed by:

If your survey will be administered more than once, please indicate the interval or dates of future administration:

Data Format Preference

The IRP Office will provide you with frequency distribution of your survey results. If you need additional analysis of the data, please describe:

Desired format for data:
Excel Text SPSS

Survey Questions

Please e-mail your survey questions to irp@humboldt.edu after submitting this form. Please reference "survey submission" in the subject line.

Additional comments for the Institutional Research and Planning Staff:

Note:Depending on IRP scheduling, your requested date of completion does not guarantee that your request will be completed by this date. An IRP staff member will be in contact with you regarding this submission.

Your Signature

By providing your electronic signature below, you certify that you have either obtained Institutional Review Board (IRB) approval to proceed with this survey administration or that you have determined that your survey administration does not require IRB approval. If you are not sure if you need IRB approval, please visit www.humboldt.edu/hsuf/irb.php for contact information, policies and forms.

Electronic signature (enter your name):

Date:

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