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* 1. What is the name of your organization or college/university?

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* 2. 2. Do you currently have a community-based learning infrastructure at your school? If so, please briefly describe.

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* 3. What would you like to learn about at a Midwest science shop meeting?

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* 4. Please list any other topics of interest and note if you would be willing to facilitate a discussion about this or another listed topic.

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* 5. Please describe any steps toward developing a community-based research or engagement "brokerage hub" for your institution.

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