ࡱ> O ^bjbj'' .xEeEe ########8-$d$#u^%%'^'''r(v(D,)$]]]]]]]$eadX]]#P)r(r(P)P)]##''/^<*<*<*P)#'#']<*P)]<*<*lX4]'J()jZ>]0ܰ6<*se|]se#]P)P)<*P)P)P)P)P)]]<*P)P)P)u^P)P)P)P)seP)P)P)P)P)P)P)P)P) ": IRB Survey Participation Form Form version: February 2015In MS Word, click in the white boxes and type your text; double-click checkboxes to check/uncheck. This form is to be used for participation in surveys that originate from a group outside of NIC 1. Todays Date FORMTEXT       2. Principal Investigator (PI) and Organization conducting the survey or where survey originates Name  FORMTEXT       Organization FORMTEXT      Contact Phone  FORMTEXT       E-mail FORMTEXT       3. Survey and Purpose  Identify the type of Survey and the benefit for NIC community participating in the survey.  FORMTEXT      Identify if this will be a one-time participation survey or if NIC will be participating regularly in this survey and how frequently this will occur.  FORMCHECKBOX  One time participation Length of study:  FORMTEXT       FORMCHECKBOX  NIC will participate regularly Identify how frequently we will participate.  FORMTEXT      Administration of the Survey: FORMCHECKBOX  Survey will be administered by the organization conducting the studyWhat specific NIC population will be targeted?  FORMTEXT      What information is the organization asking for NIC to provide to them?  FORMTEXT       FORMTEXT       FORMCHECKBOX  Survey will be administered by NICIndividual or group responsible  FORMTEXT      How will the data be collected and where will it be stored?  FORMTEXT       4. 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FORMCHECKBOX  Explanation letter of the purpose of the survey including details on how the survey will be conducted, duration of data collection, how the data will be collected and stored and how the results will be used.  FORMCHECKBOX  A complete copy of the survey questions.  FORMCHECKBOX  A copy of the Informed Consent.  FORMCHECKBOX Documentation to show that participants will be made aware of appropriate local resources that are available if the participants requires it as a result of participating in the study.  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