Survey/Interview Screening and Recommendation Form

Date

Full Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Name of Facility

Type of Facility

Your Position

What do you want to know?

What is your purpose for conducting the survey/interview?

How do you plan to conduct the survey or interview?

Include timeline and the number of program managers you plan to survey or interview.

What are the proposed survey or interview questions for program managers?

Please upload.

Accepted file types: doc, pdf, Max. file size: 2 GB.

What are your intentions for the use of the information?

What are the benefits to immunization programs if they participate in the survey or interview?

What is your expectation of AIM's role in assisting with this survey or interview (if any)?

Are you receiving funds to support your survey or interview?

Yes

Funding Source

Funding Detail

Would you agree to share with AIM the identified information you collect?

Yes

Would you agree to present results to AIM membership prior to the public release of the information?

Yes

For More Information

Please contact Katelyn Wells, AIM Chief Research and Development Officer, at (301) 424-6080 for additional information.