Survey Screening Form

Please enter your contact information

Full name

Email

Phone #

Your answer to question 1 (Email) must be a valid email address.

Your answer to question 1 (Phone #) must be a valid U.S. or Canadian Phone Number.

Do you intend on surveying NEOMED students, faculty and/or staff?

1. Yes
2. No

Your affiliation with NEOMED

1. Clinical Faculty
2. Rootstown Based Faculty
3. Staff

1. Student
2. Alumni
3. Other (Please specify)Please specify

Class

1. M1
2. M2
3. M3
4. M4
5. P1

1. P2
2. P3
3. P4
4. Graduate Student

If you have a faculty adviser(s) for your survey, please enter their contact information.

Name 1

Email address 1

Name 2

Email address 2

Is your faculty advisor aware that you are completing this Survey Request Form?

1. Yes
2. No
3. I don't have a faculty advisor.

By clicking "Yes", I certify that my faculty advisor has approved the proposed survey.
Please note that the IR office will contact your faculty advisor(s) and will not process your request before a confirmation from them is received.

Contact your faculty advisor. Consult with them on your survey and make them aware that you are completing the Survey Request Form.

Which of the following surveys are you planning to create?

1. A Survey for Program Evaluation, Quality Improvement or Environmental Scan
2. IRB-approved Survey for research purposes
3. Not sure

Definitions

Program Evaluation:  systematic method for collecting, analyzing, and using information to answer questions about feasibility, effectiveness and efficiency of projects, policies and programs, and to support decision-making.
 
Quality Improvement study: assessment of systematic and continuous actions that lead to measurable improvement of products, processes and systems.
 
Environmental Scan: systematic process of gathering information about events and their relationships within an organization's internal and external environments to identify l opportunities and threats. The basic purpose of environmental scanning is to help management determine the future direction of the organization.

Click here to determine if your project is a research study requiring IRB approval or is a program evaluation/quality improvement.

Have you received IRB approval?

1. Yes
2. No

The IR Office will not provide support for your project before receiving evidence for NEOMED IRB approval.

Please send IRB Approval to instresearch@neomed.edu.

What stage are you in the IRB approval process?

1. Preparing proposal
2. Submitted - pending approval
3. OtherPlease specify

Which of the following IR services will you need?

1. Consultation (The IR office provides advice on design of research and program evaluation studies; survey development and analysis of survey results.)
2. Data Analysis (A process of inspecting, cleansing, transforming, and modeling data for the purpose of discovering useful information, informing conclusions, and supporting decision-making)
3. Survey Development (The process of developing a survey instrument that includes the necessary and sufficient number of questions to efficiently collect data from a target population for the purpose of exploring a phenomenon or, evaluating processes and/or services)
4. Survey Distribution (The method by which the survey is delivered to the participants)
5. Other (Please specify)Please specify

Title of Survey

Include a brief description of the purpose of the survey

What survey platform are you planning to utilize?

1. Snap Survey
2. SurveyMonkey

1. SurveyMonkey Enterprise
2. Verint

1. Qualtrics
2. Other (Please specify)Please specify

Targeted Audience

1. Clinical Faculty
2. Rootstown Based Faculty
3. Staff
4. Students
5. Alumni
6. Other (Please describe)Please specify

According to NEOMED Survey Policy, colleges have to approve any survey distributed to their students.
The IR Office will contact the appropriate college administrators for final approval and scheduling for administration of the survey. This process may take up to five working days.
The IR Office will notify you of the colleges' approval as soon as a decision is made.

Class

1. M1
2. M2
3. M3
4. M4
5. P1

1. P2
2. P3
3. P4
4. Graduate Student

How would you like to distribute your survey?

Survey Link Distribution - This explains how the survey is delivered and distributed. There are two methods.

Individual Email Link: Each survey participant will receive a unique link to the survey via email. This will allow for  saving and tracking individual responses. Email reminders will ONLY be sent to participants who have not completed the survey at a specific time point.

Anonymous Open Link: One link will be published that can be posted on a variety of media (email, website, social media, etc.). Any number of survey participants may use and re-use this one survey link. There is no way to identify the individual submitting a specific response.

The IR Office follows strict guidelines to protect the confidentiality of survey responses.

Survey Link Distribution

1. Individual Email Link
2. Anonymous Open Link

Who will provide the email list?

1. I will provide it.
2. I would like Institutional Research to provide it.

Anticipated Date of Distribution (This may change based on permission from respective college)

Survey Open

Format: mm/dd/yyyy

1st Reminder

Format: mm/dd/yyyy

2nd Reminder

Format: mm/dd/yyyy

Survey Close

Format: mm/dd/yyyy

Your answer to question 10 (Survey Open) must be a valid date.

Your answer to question 10 (1st Reminder) must be a valid date.

Your answer to question 10 (2nd Reminder) must be a valid date.

Your answer to question 10 (Survey Close) must be a valid date.

Anticipated Date of Distribution (This may change based on permission from respective college)

Survey Open

Format: mm/dd/yyyy

Survey Close

Format: mm/dd/yyyy

Your answer to question 10a (Survey Open) must be a valid date.

Your answer to question 10a (Survey Close) must be a valid date.

If you are planning to use the services of the IR office, how would you like to receive the survey results?

1. Data file
2. Summary report
3. Reports based by respondent group
4. Other (Please specify)Please specify

How will you secure the data once collected?

Will the survey results be used for presentation/publication?

1. Yes
2. No