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E-AHPBA Scientific & Research - Request to Circulate a Survey
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1. Survey Title
(Required.)
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2. Date of Request
(Required.)
Date / Time
Date
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1900
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3. Applicant Details:
(Required.)
Name of Applicant
Position
Address
Address 2
City/Town
ZIP/Postal Code
Country
Email Address
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4. Is the Applicant an E-AHPBA member?
(Please note that either the applicant or a senior collaborating member of the team must be an E-AHPBA member)
(Required.)
Yes
No
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5. Supervising Institution:
(Required.)
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6. Supervising Mentor:
(Required.)
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7. Team involved, their location(s) and E-AHPBA member status:
(Required.)
Upload any supporting documents for the team here:
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No file chosen
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8. Scope of proposed survey:
(Required.)
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9. Background and rationale of proposed survey:
(Required.)
Upload any supporting documents for the proposed survey here:
Choose File
No file chosen
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10. Geographic area of survey:
(Required.)
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11. A summary of the protocol demonstrating that the collection and analysis of data is consistent, reliable, repeatable, and appropriate to address the intended objective:
(Required.)
Upload any supporting documents for the summary of protocol here:
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No file chosen
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12. Summary of intended use of data gathered, plan for publications:
(Required.)
Upload any supporting documents for the summary of intended use and plan for publications here:
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No file chosen
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13. Please upload the questionnaire of the survey:
(Required.)
Choose File
No file chosen
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14. Will survey respondents be acknowledged as collaborators?
(Required.)
Yes
No
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Acknowledgement:
(Required.)
I confirm that I have read and understood the E-AHPBA Scientific & Research Endorsement Guidelines available on the E-AHPBA website and agree to adhere to the criteria outlined in this document.
I agree to provide project updates 6 months after endorsement and annually thereafter until completion or publication, and to acknowledge E-AHPBA support in all outputs.
