Survey Request Form Name: * Department or Institution: * Email: * Phone #: * Title of survey: * Purpose of survey: * Do you have IRB clearance? * (If you are not sure what the IRB is, more information can be found on its website: http://research.ku.edu/human-subjects) Yes No Unsure Who is the target population for this survey? (Check all that apply) * Faculty Staff Undergraduate Students Graduate Students Alumni Other Do you plan to request use of a university distribution list? * Yes No Unsure How often will this survey need to be administered? * One-time only Each semester Once per academic year Other What is the range of dates during which the survey will be administered? Please provide a start and end date. * Please list the questions of the survey here (or attach below): Attach list of questions Files must be less than 2 MB.Allowed file types: pdf doc docx. Has a similar survey been conducted in the past? * Yes No Unsure Do you plan to send out the survey yourself? * Yes No Unsure Do you want AIR to administer the survey? * Yes No Unsure CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. What code is in the image? * Enter the characters shown in the image.