EmailMe Form - Community Insights Study Submission Form

BACKGROUND INFORMATION

Name *

First Last

Who is the primary contact or owner of this project?

Email *

Organization Name *

Please list any additional stakeholders, if any, who should be included on all communication regarding this project:

For each individual, please provide name and email address.

STUDY INFORMATION

1) Which participant source would you like to survey? Please note that some sample sources may be used in combination with each other and the source type may be dependent on your contract. *

Online Patient Community (opted-in through patient experience survey)

Consumer panel

Link that your organization distributes

List of emails provided by your organization

I don’t know

2) If CONSUMER PANEL selected in (1) above, what is the desired study geography?

Please specify which market(s) you would like to field in. This can be a list of zip codes or counties, or a market defined in your Market Insights tool. Community Insights studies using consumer panel can target respondents at the zip code, city, county, or state level.

3) If CONSUMER PANEL selected in (1) above, please provide the desired total n-size (number of responses collected) for consumer panel respondents for this survey, if known.

The total n-size will be dependent on the number of remaining consumer panel respondents in your contract as well as feasibility for this survey.

4) Who is the desired audience for this study? *

5) Would you like this study fielded in English only, or English and Spanish? *

English only

English and Spanish

Please note that some surveys are not eligible for Spanish translation (50 or more potential respondents must be available), and adding Spanish translations will increase the project’s timeline.

6) Please describe the research you are wanting to conduct. Feel free to include information about what problem you are trying to solve through this survey and how you might use the data from the survey to inform decisions. *

7) If you already have some questions in mind that you’d like to ask in the survey, please use this space to detail those questions.

8) If you have any specific demographic, psychographic, experience, or geographic segments you want to compare when analyzing the survey’s results, please list them here.

9) If available, please attach any document that further detail your research plan, goals or objectives.

10) NRC Health is excited to share example research with other customers upon request. To help us build a robust library of de-identified past studies, we are looking for your voluntary participation in creating these examples. Would you allow us to de-identify your study’s results once your project is complete and the results are shared with you? *

Yes

No

Unsure

Your answer to this question is not a condition of initiating or completing this survey. It is a voluntary way to help share data and insights with other organizations across the country.