Survey Request Form
Client First Name:
*
Client Last Name:
*
Email:
*
Phone:
Are you currently affiliated with the University of Michigan?
*
YES
NO
U-M School or department:
*
Please select a School
Architecture & Urban Planning
Art & Design
Business
Dentistry
Development
Education
Engineering
Environment and Sustainability
Human Resources
Information
ISR
Kinesiology
Law
Literature, Science, and the Arts
Michigan Medicine/UHS
Music, Theatre & Dance
Nursing
Pharmacy
Public Health
Public Policy
Rackham School of Graduate Studies
Shared Services
Social Work
OTHER
Please specify:
Are you currently:
Please select your Status
Faculty member
Staff member
Graduate student
Undergraduate student
Other
Please specify:
Which of the following best describes your institution?
*
Please select one
College or University
Non-profit Organization or Foundation
Government
Private Company
Other
Please specify:
What is the name of your institution or organization?
Are you interested in having SRC Survey Research Operations carry out data collection for your research?
YES
NO
Unsure
Which of the following services are you interested in receiving from SRC Survey Research Operations?
Questionnaire design consultation
Sample design and/or weighting
Coding of open-end questions
Data Analysis and/or reporting
Other:
Specify:
Project Title (if known):
(in 250 characters)
Briefly describe your research topic:
(in 250 characters)
What modes are you considering for data collection?
Web
In-person interview
Telephone or video interview
Mail
Focus Groups
Other:
Specify:
Are you interested in having SRO collect any physical measures or bio-markers?
YES
NO
Unsure
Please select the BioMarkers:
Height, weight or other physical measures
Saliva
Dry Bloodspot
Other:
Specify:
What number of completed interviews or surveys do you hope to collect?
What is the population from which you plan to select your sample of respondents?
Enter the approximate date you plan to launch data collection.
About how long do you expect it will take for a respondent to complete your survey?
(Survey length in minutes)
Who do you expect to provide funding?
Please select funding source
NIH
NIA
NSF
DoD
Federal - Other
Foundation Funding
Private Funding
UM Internal Funding
Other
Please specify:
Specify:
On what date do you expect to submit a proposal?
Is there any additional information we should know about the proposed study?
Are you the Principal Investigator for this research?
YES
NO
PI Names:
Submit Inquiry