MOA Member Project/Survey Request

First Name *		Last Name *
Email Address *
Phone *
Organization
Advisor (if applicable)
What is the purpose of your survey/project? *
Is this survey for the purpose of a research study? *	Yes No
Has the research been approved or deemed exempt by an Institution Review Board? *	Yes No N/A
Please upload the IRB letter with their notification of approval/exemption.
How will the results of this survey/project benefit the membership or the association? *
How do you propose the survey/project results be published?A copy of the survey/project results is required to be submitted to the MOA prior to publication.
How does this survey contribute to the MOA Mission Statement?
Method of survey/project distribution (please choose only one) *	Mailing - submit $50 for labels (surveyor responsible for printing and mailing survey) MOA Education Event distribution Michigan Optometrist magazine E-blast
Survey/project projected distribution date:MM/DD/YYYY
Survey/project submission deadline date:MM/DD/YYYY
Please upload a file of questions to be asked in the survey or copy and paste below in Comments
Additional Comments

Calendar more

Edit This Favorite