SOCCS Survey Application Question Title * 1. Date of application Date / Time Date Question Title * 2. Principal Investigator Question Title * 3. Survey Title Question Title * 4. Institution Question Title * 5. Email address Question Title * 6. Phone number Question Title * 7. Choose one of the categories below: Undergraduate Medical Student Resident Training Fellow Early Career Advocate Administrator Industry Representative Other (please specify) Question Title * 8. Are you an AAP Section on Cardiology & Cardiac Surgery (SOCCS) Member? Yes No Question Title * 9. If not a member, who is your member sponsor? Please list their name and institution. Question Title * 10. IRB Approval: Yes No Awaiting SOCCS Survey Committee Review Other (please specify) Question Title * 11. Background & Brief Description Question Title * 12. What are the benefits of having this survey filled out by SOCCS Members? Question Title * 13. Proposed Dates of Survey Distribution Question Title * 14. Survey link Question Title * 15. Or Survey Attachment PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Or Survey Attachment Question Title * 16. Do respondents receive any incentives to participate? Yes No If yes, what is the incentive? Question Title * 17. Do you have any funding? Yes No If yes, please describe. Question Title * 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? Question Title * 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 Done
