NCS Survey Submission Form

Based on our experience, it is highly recommended for investigators to put forward incentive. This can be done as a lottery where participants will have the opportunity to voluntarily provide their contact information.

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* 1. Contact Information

Name

Title

Institution

Email Address

Phone Number

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* 2. Describe the background of the survey (include citation of relevant literature and the gap the survey will address) (max 500 words)

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* 3. Describe the aims of the study (max 250 words)

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* 4. Describe what methods that you utilized for the survey development? (max 250 words)

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* 5. Describe the data analysis plan (max 250 words)

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* 6. Describe the significance and implications of this study (include impact and importance of the survey for professional practice and/or policy in relation to the current body of literature or state of practice) (max 300 words)

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* 7. Provide IRB approval date

Date / Time

Date

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* 8. Upload IRB approval letter

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

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* 9. Specify the target audience (Select any that apply)

All Members

Restrict to MDs

Restrict to APs

Restrict to RNs

Restrict to Pharmacists

Restrict to U.S. users

Restrict to International users

Restrict to Trainees (fellows, residents, medical students)

Other (please specify)

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* 10. Upload file containing survey questions (PDF or Word Document)

PDF, DOC, DOCX file types only.

Choose File

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* 11. Provide the link to the online survey (this is in addition to the survey document uploaded in the previous question; this is the link that survey responders will use)

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* 12. Enter approximate duration of survey (minutes)

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* 13. List any other routes of survey dissemination in the past or the future

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* 14. Specify any conflicts of interest

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* 15. List any sources of funding, if applicable

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* 16. List any protected health information or other identifiers collected in survey

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* 17. Based on our experience, it is highly recommended for investigators to put forward incentive. This should be done as a lottery where participants will have the opportunity to voluntarily provide their contact information. Do you plan to put forward an incentive to survey responders?