Survey Application

Survey Application
Please complete the following form to request a review of your survey project.
1. Survey Author Name and credentials
Contact Email:
Are you currently a SCCM member?

YesNo
2. Is this survey a task force or committee project?

Yes (please indicate below)No
If yes, name of task force or committee
3. Survey Title
4. Date Submitted

MonthDayYear
5. Posting date that you are requesting for your survey

MonthDayYear
Remember to allow at least 6 weeks for review prior to this date.
6. Provide a summary of the research activity and rationale for conducting the study. State why you believe your survey is original, feasible, important, and relevant to ICU care. (add additional space as needed).
7. Provide a letter of IRB approval, exempt status, or "closed" status for this project.
8. Please attach an electronic copy (.doc or .pdf) of the actual survey tool
9. Provide the wording to be included in the direct mail or eNewsletter to the membership regarding your survey
10. Provide the link to your survey
11. Please indicate from the categories below the SCCM current members that you would like this survey to be directed to.

All SCCM MembersPhysician AssistantsNursesPhysical TherapistsRespiratory TherapistsPharmacistsDietitiansOther (please indicate below)
Specify Other Category
12. Please indicate audience

Adult audience onlyPediatric audience onlyBoth Adult and Pediatric audience
Remember that your survey should ideally be directed to a multi-professional target audience.
13. Please indicate how you would like this survey disseminated

Direct email to target audience ($3,000 for SCCM members and $4,000 for non-members)Inclusion of survey description and link in SCCM eNews ($500 for SCCM members and $750 for non-members)
Additional Info
Should be Empty: