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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 anonymous@umich.edu 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 No 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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