Name of investigator:

Name of institution:

Purpose of request (i.e. master's thesis, dissertation):

Chesapeake Department (if applicable):

Email address:

Please complete the following items. Documentation will be requested if needed.

Purpose of Study:

Aims/objectives (hypothesis):

Methodology (what participants will be asked to do):

Indicate where this study will be conducted: Select one... All Campuses Wye Mills Easton Memorial Cambridge Other (please specify below)

If other is selected, please specify:

Describe how your study will gain informed consent from participants. If under 18, parent consent is needed. A completed survey infers consent by the participant, as long as all details were disclosed.

Describe how you will ensure confidentiality of responses.

Describe how you will ensure data security as the data is collected, stored and analyzed.

Provide a statement of assurance that results will not be disaggregated to the level that students or Chesapeake can be identified.

Describe the implications of these results for students and how your findings will benefit Chesapeake students.

Describe how you will return the results of the study to Chesapeake (i.e. summary report).