Research Related Survey Request Form

Prior to approval of access to the EAST web mail system, the investigator must:

  • Complete the online “Research Related Survey Request Form”.
  • Submit a brief synopsis of the purpose, methodology, anticipated results, and a copy of the survey tool. All documents can be emailed to
  • Provide documentation of submission for review and decisions regarding approval or exemption of the study by the investigator’s home institution IRB.
  • Pay a non-refundable $150 application fee to include review and feedback from the EAST Research-Scholarship Committee.  Please note, only credit cards are accepted.
  • Complete the EAST Research Related Surveys - Conflict of Interest Disclosure Form found here.  Surveys that are submitted without completion of the Conflict of Interest Disclosure Form WILL NOT be reviewed.

 After all documents are submitted and the appropriate fees are paid in full, the project will then be reviewed by the Research-Scholarship Committee to determine suitability for dissemination to the membership.

On approval of the survey, an additional $250 fee would be processed for distribution of the survey to the EAST membership.  

Contact Information

Include full name & degrees/credentials
Any correspondence will be sent to this email address
Best contact number to reach you at if needed

Survey Information

Please limit to 2-3 sentences

Payment Details

A non-refundable $150 application fee applies. If approved, an additional $250 fee would be processed for survey distribution.

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Policies on Solicitation of the EAST Membership for Research Related Purposes

  • The EAST Research-Scholarship Committee will review requests to survey the members of EAST for research related purposes.
  • Requests to survey the EAST membership for research related purposes will be reviewed by the EAST Research-Scholarship Committee on a quarterly basis occurring in March, June, September, and December. Survey requests must be received by the 1st of the month during which it will be reviewed (March, June, August, October/November).
  • As we receive many such requests each year and are charged by the EAST Board with limiting the number of surveys distributed by EAST, a maximum of three (3) survey requests for research related purposes will be approved on a quarterly basis.

Eastern Association for the Surgery of Trauma

633 N. Saint Clair Street, Suite 2400 Chicago, IL 60611-3295 (312) 202-5508 phone (312) 202-5064 fax
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