(
*
All fields are required)
• College:
Main Contact Person
Secondary Contact Person*
• First Name:
• Last Name:
• Position:
• Email:
• Phone:
• First Name:
• Last Name:
• Position:
• Email:
• Phone:
* The secondary contact person is required so we have someone to reach out to with questions and/or to share the report/data if we are unable to get ahold of the primary contact person.
• Date survey will start (needs to be 2 weeks before spring break starts or 1 month after it ends. Please select date betwen
February 1st and April 15th
.)
=== Month ===
February
March
April
=== Day ===
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• Would you like to add additional questions (up to 10 max)?
Yes
No
Not Sure
• Would you like to add the optional mental health module?
Yes
No
Not Sure
• Would you like to add the optional wellbeing module?
Yes
No
Not Sure
• Would you like to offer an incentive to participants?
Yes
No
Not Sure
I acknowledge that Prevention Insights will combine my school’s data with the data of all other schools for reporting purposes. No school identifiers will be included in the aggregated reporting of the statewide data. Prevention Insights may share the aggregated data (without school identifiers) with researchers to further study substance use, mental health, and problem gambling among college students. Prevention Insights may disclose the names of participating schools. However, individual school-level data will not be shared with third parties unless the subject school provides written permission for Prevention Insight to release such data to third parties.