Participation Request Survey

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1. District, Institution or Agency Name:

District, Institution or Agency Name:

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2. What would you like your portal url to be? (i.e. http://______.blackboard.com)

What would you like your portal url to be? (i.e. http://______.blackboard.com)

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3. Organization Type:

Organization Type:

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4. Person completing this request: Please complete the contact information below.

Person completing this request: Please complete the contact information below. Name:
Company:
Address:
Address 2:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

5. Technical Contact Information

Technical Contact Information Name:
Company:
Address:
Address 2:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

6. Distance Learning Contact Information

Distance Learning Contact Information Name:
Company:
Address:
Address 2:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

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7. Do you currently have an online course management system?

Do you currently have an online course management system?

8. If you answered yes to question 6, what course management system are you currently using?

If you answered yes to question 6, what course management system are you currently using?

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9. Do you have a student information system or student management system?

Do you have a student information system or student management system?

10. If you answered yes to question 8, what system are you currently using?

If you answered yes to question 8, what system are you currently using?

11. If you answered yes to question 8,is the student system integrated with your online learning management system?

If you answered yes to question 8,is the student system integrated with your online learning management system?

Participation Request