E-AHPBA Scientific & Research - Request to Circulate a Survey

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* 1. Survey Title

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* 2. Date of Request

Date / Time

Date

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* 3. Applicant Details:

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)

Yes

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* 5. Supervising Institution:

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* 6. Supervising Mentor:

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* 7. Team involved, their location(s) and E-AHPBA member status:

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* Upload any supporting documents for the team here:

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* 8. Scope of proposed survey:

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* 9. Background and rationale of proposed survey:

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* Upload any supporting documents for the proposed survey here:

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* 10. Geographic area of survey:

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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:

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* Upload any supporting documents for the summary of protocol here:

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* 12. Summary of intended use of data gathered, plan for publications:

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* Upload any supporting documents for the summary of intended use and plan for publications here:

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* 13. Please upload the questionnaire of the survey:

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* 14. Will survey respondents be acknowledged as collaborators?

Yes

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* Acknowledgement:

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.

Question Title

* 1. Survey Title

Question Title

* 2. Date of Request

Question Title

* 3. Applicant Details:

Question Title

* 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)

Question Title

* 5. Supervising Institution:

Question Title

* 6. Supervising Mentor:

Question Title

* 7. Team involved, their location(s) and E-AHPBA member status:

Question Title

* Upload any supporting documents for the team here:

Question Title

* 8. Scope of proposed survey:

Question Title

* 9. Background and rationale of proposed survey:

Question Title

* Upload any supporting documents for the proposed survey here:

Question Title

* 10. Geographic area of survey:

Question Title

* 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:

Question Title

* Upload any supporting documents for the summary of protocol here:

Question Title

* 12. Summary of intended use of data gathered, plan for publications:

Question Title

* Upload any supporting documents for the summary of intended use and plan for publications here:

Question Title

* 13. Please upload the questionnaire of the survey:

Question Title

* 14. Will survey respondents be acknowledged as collaborators?

Question Title

* Acknowledgement:

* 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)