OFFICE OF INSTITUTIONAL RESEARCH INTERNAL / EXTERNAL REQUEST FORM

	Date of Request    (MM/DD/YY format)

	Name of Requestor

	Department

	Status
	Faculty
	Staff
	Student
	Other

	Describe the request in detail (e.g., survey description, semesters desired, specific locations, etc.):

	What is the institutional / instruction / education purpose of this request?

	How will the information be used?

	Will the information / research be published, and if so, where?

	How will the confidentiality and security of the information be assured?

Please allow our office a two week time turn around for all requests.