ISSWSH Survey Request Form
Name
*
First Name
Last Name
Email
*
example@example.com
Are you a member of ISSWSH?
*
Yes
No
Title of Survey
*
Please provide a brief description of the Survey for inclusion on the ISSWSH website and promotions:
*
Target Audience (check all that apply)
*
All ISSWSH Members
Physician Members
Non-Physician Members
Student/Residents/Fellows
Other
Please describe in detail the purpose of this survey and how it aligns with ISSWSH:
*
Please provide a link or copy of your survey below.
Survey Link
*
Copy of Survey
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Date survey to begin
*
-
Month
-
Day
Year
Date
Date survey to end
*
-
Month
-
Day
Year
Date
Acknowledgements:
An acknowledgment should be included that this survey and its results are independent of ISSWSH and the results do not reflect the opinion of the society or its leadership in an official capacity.
Upon conclusion of survey, aggregate results or overview of findings should be submitted as an abstract at the next available annual meeting, if appropriate.
Any names or information collected in the survey will be used only for the purpose of the survey and cannot be shared with any outside entities.
My signature in agreement with the above acknowledgements.
*
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