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* 1. Name/contact information of individual requesting survey:

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* 2. I am an:

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* 3. Please provide a brief description of the survey project, including the purpose and intended use of results.

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* 4. When do you intend to begin collecting responses for your survey?

Month/Day

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* 5. When do you intend to stop collecting responses for your survey?

Date / Time

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* 6. What population do you intend to survey? Select all that apply.

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* 7. Does your survey require IRB approval? If you are unsure, contact the Antioch Institutional Review Board (irb@antiochcollege.org).

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