Fields marked with an asterisk (*) are required.

• Contact Information

• Name *

  First Last
• Department *
• Phone *

  - Area Code - Prefix Line Number
• Email *

• Survey Details

• Survey Name *
• Purpose of the Survey * How will the information be used, what question(s) are you trying to answer, what populations are most relevant to your question(s)?

  How will the information be used, what question(s) are you trying to answer, what populations are most relevant to your question(s)?

• Proposed Format * Online/web survey; paper and pencil survey; focus group; interview; etc.

  Online/web survey; paper and pencil survey; focus group; interview; etc.

• Communications * Please describe the type and number of communications that will be sent to individual respondents (e.g., email, postcards).

  Please describe the type and number of communications that will be sent to individual respondents (e.g., email, postcards).

• Survey Length * How long do you expect the survey will take on average? Approximately how many questions will be asked?

  How long do you expect the survey will take on average? Approximately how many questions will be asked?

• Preferred Start Date *

  / MM / DD YYYY
• Preferred End Date *

  / MM / DD YYYY
• Alternate Start Date *

  / MM / DD YYYY
• Alternate End Date *

  / MM / DD YYYY
• Administration Date Constraints * Explain your reasoning for the dates you prefer for this survey.

  Explain your reasoning for the dates you prefer for this survey.

• Incentives * If participants will be compensated in any way, describe your plans for incentives.

  If participants will be compensated in any way, describe your plans for incentives.

• Other Comments Share any other information with the IUPUI Survey Committee.

  Share any other information with the IUPUI Survey Committee.

• Survey Population Information

• Target Population *

  Freshmen Sophomores Juniors Seniors Graduate Students Staff Faculty Non-Degree Students Auditing Students Alumni Other Other

  Indicate which populations you wish to survey (select all that apply).

• Population Details * Please describe your population in detail, indicating any targeted populations (e.g., undergraduate women, students who identify as Hispanic or Latino/a, fraternity/sorority members).

  Please describe your population in detail, indicating any targeted populations (e.g., undergraduate women, students who identify as Hispanic or Latino/a, fraternity/sorority members).

• Survey Sample Information

• Do you need the IUPUI Survey Committee to provide you a sample?*

  Yes, we would like the IUPUI Survey Committe to provide a sample. No, we will be providing our own sample.

  Note: Please provide specific details for your sample in the Indicate Sample Size section below.

• Indicate Sample Size * The total number of individuals you plan to invite to take your survey (e.g., census, 600 total individuals, 25% of the IUPUI undergraduate population).

  The total number of individuals you plan to invite to take your survey (e.g., census, 600 total individuals, 25% of the IUPUI undergraduate population).

• Sample Details & Rationale * Please indicate any special sampling instructions (e.g., stratified random sample) and explain why the desired sample is necessary.

  Please indicate any special sampling instructions (e.g., stratified random sample) and explain why the desired sample is necessary.

• Data Use and Stewardship

• Data Use *

  Accreditation Program Review Assessment Campus Improvement Departmental Improvement Personal Research Institutional Research Regional/National Survey Other Other

  Indicate whether survey data will be used for any of the following purposes (select all that apply).

• Strategic Plan

  How does the survey support the goals of the IUPUI Strategic Plan? Please indicate how the survey aligns with at least one of the goals (select all that apply).
  
  Find more information here:
  https://strategicplan.iupui.edu/goals

• Goals

  Goal 1: Promote Undergraduate Student Learning and Success Goal 2: Increase Capacity for Graduate Education Goal 3: Transform Online Education Goal 4: Optimize our Enrollment Management Goal 5: Leverage our Strengths in Health and Life Sciences Goal 6: Accelerate Innovation and Discovery through Research and Creative Activity Goal 7: Deepen our Commitment to Community Engagement Goal 8: Strengthen Internationalization Efforts Goal 9: Promote an Inclusive Campus Climate Goal 10: Develop our Faculty and Staff
• Reporting Plans * How will data be used and with whom will results be shared?

  How will data be used and with whom will results be shared?

• Data Stewardship*

  Record Data will be shared with an organization or individual outside Indiana University Record Data will NOT be shared with an organization or individual outside Indiana University

  You assume all responsibility for ensuring that student, faculty and staff record data is never shared inappropriately. If you anticipate that record data or personal information about students, faculty or staff will be shared with any organization or individual not affiliated with Indiana University, Bloomington at any point as a result of this survey, indicate here.

• FERPA Compliance

  IU's FERPA Tutorial: https://ferpa.iu.edu/index.html
  FERPA Guidance: https://research.iu.edu/compliance/human-subjects/guidance/ferpa.html

• FERPA Compliance *

  I certify that all survey researchers have completed IU's FERPA Tutorial and familiarized themselves with FERPA Policies. I understand that, if approved, the sample I am given will exclude individuals under 18 years of age and individuals who have filed a formal FERPA restriction to prevent sharing of their directory information.

  You assume all responsibility for ensuring FERPA compliance. Please indicate your acknowledgement of this responsibility here.

• Sample Design

  Samples for campus-wide surveys are compiled based on your population criteria and the recommendation of the Indiana University Bloomington Survey Committee. Individuals will only be included in the sample if, at the time of sample creation, they:
  
  1. meet the agreed upon criteria for inclusion in the sample population
  2. are at least 18 years old, and
  3. have not filed a formal FERPA restriction to prevent sharing of their directory information
  
  It is not possible to update the sample to reflect changes to eligibility after the sample is created (e.g., students who turn 18 after the sample is compiled will not be added to the sample).

• I understand the sample design restrictions and acknowledge that updates to the sample cannot be made after it is compiled and delivered. *

  Confirm

• Administration Cycle and History

• Administration Cycle * How often will the survey be administered, e.g. annually, every semester, every two years, as needed.

  How often will the survey be administered, e.g. annually, every semester, every two years, as needed.

• This Survey has been administered previously at IUPUI*

  Yes No
• Approximate Date of Last Administration
• Previous Findings Share key findings from the most recent administration and any impacts of the previous administration

  Share key findings from the most recent administration and any impacts of the previous administration

• Compliance with IRB

• Current Stage in the IRB Approval Process*

  IRB approval is complete IRB approval is pending IRB approval is necessary but not yet submitted to IRB IRB approval is not required for this project

  The IUPUI Survey Committee is not responsible for ensuring compliance with IRB requirements.

• IRB Application Number
• IRB Approval Date

  / MM / DD YYYY
• IRB Approval Notice
  Attach Files

  Please attach the official IRB approval letter if available.

• Student Organizations

• Does the survey originate from a student group and/or is it intended for use by a student group or organization?*

  Yes No
• Please provide the name of the student group or organization and the name and contact information of the group’s advisor. *

• Survey Documents

• For final approval of the survey, the IUPUI Survey Committee will require the survey instrument in order to ensure that the collected data do not duplicate existing data and that the survey is respectful of students, faculty and staff, and their time.

• Survey Instrument
  Attach Files

  Please attach the survey instrument if available.

• Additional Files
  Attach Files

  Please attach other files if necessary.