Request for Survey Instrument or Related Documents

As a service to us, please fill out the following information. We would appreciate it if you would complete the entire form. The items that are required* to be completed in order to download survey instruments are profession, discipline or specialty, affiliation, city, state or country, and your email address. Your email address will not be given to others. If you do not have an email address or do not want to include your email address, please enter [email protected] in the email box below.

Name

Profession *

Discipline or Specialty *

Affiliation *

Address

City, State, Zip Code, Country *

Telephone

FAX#

E-mail Address *

Requestor Information

Health Professional

Other

Are you planning to use these surveys?

Yes

Not Sure

If yes, how are you going to use these materials?

Research Project

Education Program Evaluation

Master or doctoral project/thesis

Please read the following before submitting this form. By submitting this form, you are agreeing to abide by the statement:

You have our permission to reproduce and use this instrument and other materials as long as the University of Michigan is acknowledged in any instrument, report or publication resulting from their use.

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