Survey Policy

To obtain permission from the Office of the Provost to distribute surveys to individuals outside one's school or office, please complete all of the items on this form. If you have any questions, please call us at (212) 998-4420.

1) First Name:

2) Last Name:

3) Office:

4) Contact Number:

5) Name of Survey Instrument:

6) Enter a description of the survey instrument. If posisble, please provide a link to the survey instrument:

7) Intended Method of Administration:

8) Proposed date(s) on which survey will be administered and any pre- or post-mailings encouraging survey participation:

a) Pre Administration Mailing Date: (MM/DD/YYYY)

b) Date of Administration: (MM/DD/YYYY)

c) Post Administration Mailing: (MM/DD/YYYY)

d) Post Administration Mailing: (MM/DD/YYYY)

9) Please enter a description of any planned incentive program for respondents:

10) Please describe the purpose of the survey and how the information will be used:

11) Please provide one of the following two items:

a. Evidence that the person administering the survey has received approval from the University Committee on Activities Involving Human Subjects (UCAIHS). Committee approval is required if the findings from the survey are used for any purposes other than internal review, i.e, if findings from the survey will be used for research purposes. Research is defined by the federal government as, “a systematic investigation designed to produce generalizable knowledge”. Generally, the results of research are reported through outside publications or presented in a forum that includes individuals outside of the university. If you are unsure whether or not your survey administration requires review, contact the UCAIHS at (212) 998-4808.

b. A statement indicating that the person administering the survey will use survey findings only for internal purposes, i.e., the findings of the survey are not for research purposes, as defined above, and will not be presented or published in any public forum.

Please sign the on the line at the bottom of the page if you agree to the following statement:
"Acceptance of authorization to administer the survey establishes an obligation on the part of the individual(s) to use these data responsibly in which the person(s) will not redistribute the data to others within or without the University, unless the individual(s) is an authoritative source for and an authorized distributor of the data and the recipient(s) is authorized to receive the data. Moreover, the data is not allowed to be stored on computers or servers outside NYU, unless such storage is authorized."

Signature:
Date: