| Date: |
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| Department: |
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| Requestor: |
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| Supervisor: |
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| Email: |
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| 1. Briefly describe the survey being requested: |
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| 2. When does the survey have to be administered? (Is this survey time-specific?) |
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| 3. When are the analysis results needed? (Please be specific.) |
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| 4. What level of analysis is needed? |
Raw data only
Frequencies and descriptive data, no narrative
Frequencies and descriptive data w/narrative summary
Full study report w/data tables and narrative
Other: |
| 5. Will the survey audience include: (Mark all that apply) |
Students
Faculty
Staff
Employers
Community Members
Other: |
| 6. Approximate sample size or how many surveys will be distributed? |
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| 7. Will the survey format be: (Mark all that apply) |
Scannable
On-line
Focus Group
Telephone
Other: |
| 8. Will the survey be administered: (Mark all that apply) |
District-wide
Off-campus
Specific Campus/Center
Other |
| 9. Survey distribution method will be: (Mark all that apply) |
Distributed in the classroom
Mailed
On-line
Telephone
Other |
| 10A. How does the survey support the College's strategic plan? |
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| 10B. How does the survey support your departmental plan? |
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| 11. How will the survey results be used and what is the MEASURABLE outcome or benefit to the College? |
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| 12. Is there a direct cost to administering the survey? (Noel Levitz, ACT, etc.) |
No
Yes
If yes, please describe the costs. |
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