ASPS Survey Application Form

ASPS Survey Application Form
Name*

First NameLast Name
Title of Survey*
Organization or Company Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail*
ASPS Member ID
ASPS Member Sponsor *
We require an ASPS member as co-investigator if you are not a member. If you are an ASPS member, please enter NA.
Please select the type of research project you are conducting:*

Scientific or Investigative ResearchMarket or Industry Research
1. What is the subject matter of the survey/study and the research question(s) you are trying to answer?
2. Has your survey tool been distributed by any other institutions outside of ASPS?*

YesNo
If so, please list all other institutions who have distributed your survey tool :
3. Are you aware of any similar studies that have been done in this area?

YesNo
If so, please provide related references and/or explain how your study will be different:
4. Has your survey tool received approval from an IRB or been submitted for IRB review?

YesNoThe research is exempt from IRB review.
5. Who is the intended target audience to take the survey (i.e. practice demographic? practice type?)
6. How will the information collected from this survey be used?
7. Who is the audience who will be reading the findings? (i.e. professional? consumer? payor? regulatory?)
8. What is the scope of the survey (i.e. number of questions? survey design/format?)
9. Do you plan to publish the findings from this study? If so, what journals and/or other publications do you plan to utilize?
Please attach a copy of your survey questions (must be in PDF or MS Word format)

Upload a File

Cancelof
Service Charge/Fee
A one-time fee is charged for all selected survey collaborations. Non-members of ASPS may be subject to additional charges. If you are not a member of ASPS, please contact the ASPS Regulatory and Scientific Affairs Department at research@plasticsurgery.org for fee schedule.
Acknowledgment Agreement
By signing the ASPS Survey Application Form, the party requesting the survey is stating that he/she has read and understands all of the above in addition to the ASPS Survey Collaboration Agreement and service charge/fee.
Name & Title

Name Title
Date of Request

MonthDayYear
Please print a copy of this request and retain for your records.

Thank you for your submission.
Full Name

First NameLast Name
Should be Empty:

ASPS Survey Application Form

Service Charge/Fee

Acknowledgment Agreement