Survey Population Request
To be used by WIU faculty and staff to request survey distribution via Qualtrics. After submitting your survey request form, found at wiu.edu/surveys, please obtain the appropriate signatures and forward to AIMS@wiu.edu.
Contact Person
*
First Name
Last Name
Phone Number
-
Area Code
-
Phone Number
Extension
Email
*
example@example.com
Department
Department Head
example@example.com
IRB Status
Status
*
Approved
In Process
Exempt
Approval Number
IRB Approval Documentation
Browse Files
Cancel
of
Population to include
*
Students
Faculty
Staff
Campus
*
Macomb Campus
Macomb Extension
Quad Cities Campus
Quad Cities Extension
Survey Data Required
*
First Name
Last Name
Email Address
Additional Comments
Today
-
Month
-
Day
Year
Date
Survey Distribution Date (please allow 5-10 working days)
-
Month
-
Day
Year
Date
Date Difference
Please allow at least five work days.
Area Vice President Email Contact
*
provost@wiu.edu
Reply To Adddress
*
example@example.com
Subject Line
*
Message Text
*
Survey Link
Upload Survey
Browse Files
Cancel
of
WIU Authorized Signature
*
Clear
Print Name
*
First Name
Last Name
Submit
Clear Form
Print Form
Should be Empty: