Today's Date:                                   Date Needed: 

Requested by:  (List the name of Administrator, Department, Division, or Committee)

Contact Name: 

             E-Mail: 

   Project Title:  

 1. Project Description: Please describe your request in detail, including the scope, specific
     variables and time frames, etc.

 2. What questions do you want the data to answer?

 3. What format would you like the information?
Report including narrative interpretation and graphics requires extra time for consultation & editing
Hard copy table of the results
Hard copy graphics of the results
Excel file and you will do your own statistical analysis

4. How will this information impact current practice?

5. Please specify how the project supports applicable college plans (Master Plan,
    Institutional Goals, Unit Plans, divisional/departmental/program plans, etc.)

6. Will the project become recurring? Yes  How often and when? 
                                                             No         

7. Will help us measure the extent to which we meet an objective or outcome (key performance
    indicator) specified in our three-year plan. If so, please state the objective/outcome as described
    in your plan.

PLEASE CHECK EACH OF THE FOLLOWING THAT APPLIES TO YOUR PROJECT:

8. Required for departmental, divisional or institutional accreditation.

9. Will help assess student learning and success.

10. Will provide data for a grant proposal.

11. Will provide data for program review and planning.

12. Other

  13. Please explain how you intend to use the information. In other words, as a result of
        this activity what will you have gained?