*************************************************************************************************************

* THIS PRINTED VERSION OF THE FORM IS FOR INFORMATION PURPOSES ONLY. * * YOU MUST COMPLETE AND SUBMIT THE FORM ONLINE AT * * GO.NCSU.EDU/SURVEY.REGISTRATION.FORM * NC State Survey Registratin Frm Intrductin Any persn planning n administering a survey t NC State students, alumni, faculty, staff, and/r administratrs is asked t cmplete the Survey Registratin Frm. Thse nt affiliated with NC State must first cmplete the External Request Frm t get permissin t administer a survey t NC State students, alumni, faculty, staff, and/r administratrs. After apprval is granted, the external requestr must cmplete the Survey Registratin Frm. Limited infrmatin prvided n the Survey Registratin Frm (i.e., the name f the survey, the survey ppulatin, and field dates) will be psted directly t a University-wide accessible Ggle Survey Activities Calendar, and a cmplete cpy f the Frm will be accessible via a link n the Calendar. The Frm prvides an ptin t request that the prject infrmatin be exempt frm psting t the Calendar. All thse planning n administering a survey are encuraged t cnsult the Survey Activities Calendar prir t cnfirming field dates in rder t limit the number f cmpeting surveys in the field at the same time. See http://upa.ncsu.edu/srvy/nc-state-survey-activities-calendars (Nte: NCSU lgin credentials [i.e., a Unity ID] are required t access the Calendar.) Fr mre infrmatin abut the survey registratin prcess cntact Dr. Nancy Whelchel, Assciate Directr fr Survey Research and Chair f the Survey Advisry Cmmittee, at ncsusurveys@ncsu.edu r 919.515.4184. ************************************************************************************************************* Which f the fllwing best describes the survey prject? 'Lcal' survey (e.g., A survey develped and/r administered by smene at NC State t NC State students, alumni, faculty and/r staff fr their wn purpses, including prgram assessment, research, etc.) 'Natinal' survey r ther large-scale survey with multiple institutins participating (e.g., A large-scale survey, develped and administered by smene frm utside NC State, in which a persn r unit at NC State wants ur students, alumni, faculty, and/r staff t participate, such as the Natinal Survey f Student Engagement, Natinal Cllege Health Assessment, etc.) 'External' survey (e.g., Smene frm utside NC State wants ur students, alumni, faculty and/r staff t participate in their survey prject) [If Natinal r External ] Wh is the Principal Investigatr r prject leader f the 'external' r 'natinal' Survey? (i.e., The institutin and/r nn-nc State affiliated persn wh wants t ask ur students, alumni, faculty and/r staff t participate in their survey.) Name (Last, First) Institutin/Organizatin NCSU.Survey.Registratin.Frm.SAMPLE.pdf Page 1 f 7

[If Lcal ] Please prvide the requested infrmatin abut the NC State prject leader fr the survey. NC State Prject Leader First Name Last Name Unit/Department r Campus Organizatin Phne Number Email Address Prject leader's primary status at NC State Administratr Faculty Staff Dctral Student Master's Student Undergraduate Student Other (please describe) Descriptin f the Survey Prject Descriptive name f the survey (e.g., "Graduating Senir Survey," "Faculty Satisfactin Survey") (This infrmatin will appear directly n the NC State Campus-Wide Survey Activities calendar; 100 character limit) Summary f the tpics included n the survey. Primary reasn(s) fr the survey (Mark all that apply) Prgram evaluatin Needs assessment Satisfactin survey Learning r develpment utcmes Faculty research Dctral dissertatin Master's thesis Student curse prject Other (please describe) NCSU.Survey.Registratin.Frm.SAMPLE.pdf Page 2 f 7

NC State Key Persnnel Key persnnel are members f the NC State campus cmmunity wh are affiliated with and/r have frmal respnsibilities related t the target ppulatin and/r cntent area f the survey prject. Prject leaders are respnsible fr infrming the relevant key persnnel abut their survey prject. In additin, supervisrs shuld be aware f surveys being administered by their emplyees, and instructrs and/r advisrs shuld be aware f survey prjects being cnducted by their students. Please indicate by name, title, and/r ffice the NC State administratr(s)/instructr(s)/advisr(s) wh is aware f and has apprved and/r is supprtive f this survey activity. Human Subjects Review Which f the fllwing best describes the status f yur prject with respect t apprval frm NC State's Institutinal Review Bard (IRB)? The prject has been apprved by NC State's IRB NC State's IRB determined that the prject was "Exempt" The prject is currently under review by NC State's IRB I have nt yet submitted my prject fr IRB review, but plan t d s The prject des nt fall under the purview f IRB I am unfamiliar with IRB requirements Other (please describe) If apprved r exempt Please prvide a cpy f the dcumentatin yu received frm NC State's IRB indicating yur prject was apprved r exempt. Nte: Just attach just a cpy f the letter/email yu received frm IRB, NOT yur entire IRB prpsal. [field t brwse fr and uplad dcument] If nt under purview Yu indicated that yur prject des nt fall under the purview f IRB. Please briefly explain. If unfamiliar with IRB Yu indicated that yu are unfamiliar with Institutinal Review Bard (IRB) requirements. The IRB is respnsible fr ensuring the prtectin f human subjects in research. It is very pssible that prir t administering yur survey yu are required by NC State plicy and federal guidelines t have yur prject reviewed by IRB. Please familiarize yurself with the expectatins fr IRB review. Infrmatin is available nline at http://research.ncsu.edu/sparcs/cmpliance/irb/. NCSU.Survey.Registratin.Frm.SAMPLE.pdf Page 3 f 7

Survey Administratin Hw will the survey be administered? (Mark all that apply) Online Self-administered paper/pencil Telephne Other (Please describe) On what date d yu anticipate the survey 'ging live,' and when will it clse? (This infrmatin will be included n the NC State Campus-Wide Survey Activities Calendar.) First day (MM/DD/YYYY) Last day (MM/DD/YYYY) Survey Ppulatin Which f the fllwing grups f peple at NC State are included in the survey ppulatin? Please check the bx t indicate that the survey includes a given ppulatin, and then describe any specific criteria that will be used t select frm amng that grup. (This infrmatin will appear n the NC State Campus-Wide Survey Activities calendar.) Undergraduate students (Specify any specific criteria, e.g., student athletes; Hispanics; sphmres) Graduate students (Specify any specific criteria, e.g., Cllege f Engineering; females; Master's students) Alumni (Specify any specific criteria, e.g., NC residents; May 2010 graduates) Faculty (Specify any specific criteria, e.g., nn-tenure track; assistant prfessrs) Staff (Specify any specific criteria, e.g., Human Resurces emplyees; EPA prfessinals) Administratrs (Specify any specific criteria, e.g., Vice Prvsts; Directrs) Other (Please describe) NCSU.Survey.Registratin.Frm.SAMPLE.pdf Page 4 f 7

If undergraduate students Will the survey be administered t a sample f undergraduate students meeting the criteria as described abve, r will everyne meeting the criteria be invited t participate? Please indicate the estimated number f undergraduate students meeting the criteria as described abve that will be invited t participate in the survey. (Enter as a single number, e.g., '450' rather than 'abut 450' r '400-500') If graduate students Will the survey be administered t a sample f graduate students meeting the criteria as described abve, r will everyne meeting the criteria be invited t participate? Please indicate the estimated number f graduate students meeting the criteria as described abve that will be invited t participate in the survey. (Enter as a single number, e.g., '450' rather than 'abut 450' r '400-500') If alumni Will the survey be administered t a sample f alumni meeting the criteria as described abve, r will everyne meeting the criteria be invited t participate? Please indicate the estimated number f alumni meeting the criteria as described abve that will be invited t participate in the survey. (Enter as a single number, e.g., '450' rather than 'abut 450' r '400-500') If faculty Will the survey be administered t a sample f faculty members meeting the criteria as described abve, r will everyne meeting the criteria be invited t participate? Please indicate the estimated number f faculty meeting the criteria as described abve that will be invited t participate in the survey. (Enter as a single number, e.g., '450' rather than 'abut 450' r '400-500') If staff members Will the survey be administered t a sample f staff members meeting the criteria as described abve, r will everyne meeting the criteria be invited t participate? Please indicate the estimated number f staff members meeting the criteria as described abve that will be invited t participate in the survey. (Enter as a single number, e.g., '450' rather than 'abut 450' r '400-500') NCSU.Survey.Registratin.Frm.SAMPLE.pdf Page 5 f 7

If administratrs Will the survey be administered t a sample f administratrs meeting the criteria as described abve, r will everyne meeting the criteria be invited t participate? Please indicate the estimated number f administratrs meeting the criteria as described abve that will be invited t participate in the survey. (Enter as a single number, e.g., '450' rather than 'abut 450' r '400-500') If ther Will the survey be administered t a sample f the ther grup(s) meeting the criteria as described abve, r will everyne meeting the criteria be invited t participate? Please indicate the estimated number f the ther grup(s) meeting the criteria as described abve that will be invited t participate in the survey. (Enter as a single number, e.g., '450' rather than 'abut 450' r '400-500') Additinal Infrmatin Please use the space belw t prvide any additinal infrmatin yu wish t share abut this survey prject. All infrmatin prvided in this Survey Registratin Frm will either be psted directly t the NC State Survey Activities Calendar, r will be accessible via a link n the Calendar. Only thse with NC State lgin credentials (i.e., a Unity ID) will be able t access the Calendar and the infrmatin abut survey prjects psted t it. Please indicate if yu wuld like t request that yur survey prject be EXCLUDED frm the calendar. If yu make such a request, yu will be given the pprtunity t prvide yur reasn fr ding s belw. I wuld like t request that my survey prject be EXCLUDED frm the Survey Activities Calendar I understand that the infrmatin prvided in this frm will be psted t the Survey Activities Calendar If Excluded Please use the space belw t explain why infrmatin abut this survey prject shuld NOT be psted t the Survey Activities Calendar. Yur request will be reviewed, and yu will be infrmed f the decisin within ne week f submitted this frm. NCSU.Survey.Registratin.Frm.SAMPLE.pdf Page 6 f 7

Thank yu fr cmpleting the Survey Registratin Frm. Yu can select "Previus" if yu wish t review/edit yur answers. When yu click n "Submit" yur frm will be submitted. Yu will then see anther page, then taken t a page with a pdf file f the infrmatin yu have prvided that yu can save fr yur recrds. NCSU.Survey.Registratin.Frm.SAMPLE.pdf Page 7 f 7