OSDBU Internal Survey Request Form

VA OSDBU Survey Request Form

The information is necessary to determine your survey requirements, ensure accuracy of the collected data, and to estimate completion date. Submit the completed form via email to [email protected]. Enter Survey Request Form in the subject line. Requests are prioritized by Strategic Outreach and communications (SOC) based on urgency and submission date.

Basic Information:

Requestor Name: Click here to enter text. Title: Click here to enter text.

OSDBU Directorate:

Email: Click here to enter text. Phone: Click here to enter text.

Submission Date: Click here to enter a date.

Will the collected data be restricted to internal VA use only?

NOTE: There is a five-day Office of Management and Budget (OMB) clearance process for data restricted to internal VA use. Data disseminated outside of VA is subject to a sixty-day OMB clearance process.

☐ Yes ☐ No*

*SOC will contact you for additional information

Anticipated Survey Launch Date: Click here to enter a date.

Please consider the appropriate OMB clearance process timeline when determining the anticipated survey launch date.

Requested Survey Details:

Survey Purpose: Click here to enter text.

Survey Objectives – specific areas for research: Click here to enter text.

Target Audience – define who will be surveyed: Click here to enter text.

Survey Delivery Method:

Please provide additional information if Delivery Method - Other is selected.

Click here to enter text.

Respondent Contact Information: Attach a list in Microsoft Excel format of applicable respondent contact information (e.g., First Name, Last Name, Email Address, Phone Number, etc.).

Respondent Contact Information Source: (e.g., VIP, AST, DAP, NVSBE Registration, SAM Database, etc.)

Click here to enter text.

Do you have recommended survey questions?

☐ No ☐ Yes*

*Please attach recommended questions in Microsoft Word format.

Please provide any additional information:

Click here to enter text.

DRAFT VA OSDBU Survey Request Form – Page 2