Application to Survey the ACG Membership - American College of Gastroenterology

Complete the Information below to Submit your Request:

The College is very limited in its survey capabilities with members, and while we have in the past occasionally sent surveys for clinical research projects, the College cannot make any assurances about fielding the survey among ACG members at this point. For those interested in surveying the ACG membership, please complete the form below to submit your request. Include all requested materials with your submission. The Research Committee will review this information on a quarterly basis. Submissions received by the following dates will be reviewed in the next cycle: January 1, April 1, July 1, and October 1. Selected surveys will be emailed to members a maximum of two times. For questions email: research@gi.org.

Are you or a member of your team an ACG member?*

Yes
No

*Important! Please note that at least one person on your Team must be an ACG member to request a survey is sent out to the ACG membership. To confirm your membership, log into https://membership.gi.org/login. For questions about your ACG membership, please email us at membership@gi.org or call 240-858-8337.

What is your ACG Member ID number?*

To look up your member ID, log into https://membership.gi.org/login then go to your My ACG page to view your membership details. Your My ACG link can be found in the upper right hand corner of www.gi.org.

Have you asked to send out a survey previously*

Yes
No

Name of Institution*

Main Topic(s)*

Primary Investigator information

Is the PI an ACG member?*

Is the PI a trainee?*

If a trainee, please describe where in your training. Enter N/A if not applicable*

Name*

First Last

Title / Position*

Email*

Point Person/ Contact:

Is the primary point of contact an ACG member?*

Name*

First Last

Title / Position*

Email*

Additional Investigator Names and Contact Info

Full name

Email

Full name

Email

Full name

Email

Survey Details:

Title of Survey*

Target Audience for Survey. Include if US or International and what type of practitioners (Ex: US physicians, GI fellows, US and International members)*

Provide the Link to your survey tool if available.*

Attach your Survey Questions*

Accepted file types: doc, docx, pdf, Max. file size: 50 MB.

Is your Survey IRB approved?*

Proof of IRB approval or exemption is required for review.

Attach your IRB approval or exemption. If you have any relevant information to IRB approval please include.*

Accepted file types: doc, docx, pdf, Max. file size: 50 MB.

Survey Methods and Questions – Attach a brief (one page) description of your survey methods, and the survey tool you plan to use (as one document)*

Accepted file types: doc, docx, pdf, Max. file size: 50 MB.

Additional Details:

How did you learn about sending a survey tool to the ACG membership?*

provide the link to your survey tool if available.

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