Appointment Request Form This form is used to match client needs and consultant skills in order to ensure the best possible services. This form must be submitted before services can be arranged. You may submit this form via email Sheila-Barron@uiowa.edu, or mail/bring the form to: Statistics Outreach Center 200 Lindquist Center The University of Iowa College of Education Iowa City, Iowa 52242 1. Name _______________________________________________ 2. E-mail address _______________________________________________ 3. Phone numbers _______________________________________________ 4. UI Status _______________________________________________ 5. College/department _______________________________________________ 6. If you are a student, please enter the name of your thesis/research advisor _______________________________________________ 7. If you do not have a UI affiliation, please enter your professional or business affiliation and mailing address _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ 8. Have you consulted with us previously? ___________________________ 9. If you answered "Yes" to the previous question, does the current consultation concern a project you have discussed with us before? ______ 10. If you have not consulted with us previously, how did you find out about our service? _____ Flyer/Bulletin board posting _____ World Wide Web posting/link _____ College of Education newsletter _____ Word-of-mouth referral Other, please specify: _______________________________________________ The Statistics Outreach Center offers free short-term statistical consulting to College of Education faculty, staff, and graduate students on projects for which funds are not available to pay a consultant. The Center also provides free consultation on grant preparation work, when the Center is written into the grant. For other services, a fee schedule can be discussed at your appointment. 11. What service are you requesting? _____ Free short-term statistical consulting _____ Collaborative analysis of your data (in exchange for paper co- authorship) _____ Paid consultation funded by a grant _____ Paid consultation with other funding 12. What dates and times work best for you? __________________________________________________________________ 13. At what stage is your research? _____ Design _____ Grant preparation _____ Data collection _____ Analysis _____ Revision or review 14. Please describe the study you are conducting and the statistical issue(s) you want to discuss. (include the description on a separate page.) If available, it is often helpful to provide us with: ¥ Copies of papers in your field which might help familiarize a consultant with the study you are conducting. ¥ Samples of questionnaires or any forms used for data collection. ¥ Relevant output from a statistical software package ¥ If you are at the data analysis stage, it is often best to bring your data to the meeting on a flash drive or CD-ROM ¥ If you have a collaborator or advisor who could provide additional valuable input, we would encourage their attendance. We look forward to meeting you, some one will contact you shortly to set up an appointment time.