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SOCCS Survey Application
1.
Date of application
Date / Time
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
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1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
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2.
Principal Investigator
3.
Survey Title
4.
Institution
5.
Email address
6.
Phone number
7.
Choose one of the categories below:
Undergraduate
Medical Student
Resident
Training Fellow
Early Career
Advocate
Administrator
Industry Representative
Other (please specify)
8.
Are you an AAP Section on Cardiology & Cardiac Surgery (SOCCS) Member?
Yes
No
9.
If not a member, who is your member sponsor? Please list their name and institution.
10.
IRB Approval:
Yes
No
Awaiting SOCCS Survey Committee Review
Other (please specify)
11.
Background & Brief Description
12.
What are the benefits of having this survey filled out by SOCCS Members?
13.
Proposed Dates of Survey Distribution
14.
Please share your Survey link.
*
15.
Please upload your survey document.
(Required.)
Choose File
No file chosen
16.
Do respondents receive any incentives to participate?
Yes
No
If yes, what is the incentive?
17.
Do you have any funding?
Yes
No
If yes, please describe.
18.
Do any members of the study team have a financial interest which might present a conflict of interest with regard to this survey?
Yes
No
If yes, what is the conflict?
19.
I will provide the Section with the results of my survey after publication or within one year of the survey, if not submitted for presentation at the SOCCS meeting or publication.
Yes
No
