ASSESSMENT and INSTITUTIONAL RESEARCH INTERNAL / EXTERNAL REQUEST FORM

	Date of Request    (MM/DD/YY format)

	Name of Requestor

	Organization or Department

	Status
	Faculty
	Staff
	Student
	Other

	Describe the request in detail (e.g., survey description, semesters desired, specific locations, etc.):

	What is the institutional / instructional / educational purpose of this request?

	Identify all individuals, by name and position (if not BPC employees, include affiliation and address) who will have access to the data you receive from us.

	Will the information / research be published, and if so, where?

	How will the confidentiality and security of the information be assured?

Please allow our office a two-week turnaround on all requests.