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Registration for CIPSSE Pilot

Questions marked with a * are required

Greetings from CIPSSE! We are very excited to pilot launch the College-in-Prison Survey of Student Engagement. Submitting the form below will give us the information we require to proceed with an administration of CIPSSE.

College-In-Prison (CIP) Program Information
If you intend to administer CIPSSE at more than one facility, you can list all of the facility names here.

Name of CIP Program

College/University Affiliation

Name of Correctional Facility

Primary Contact
This will be the person CIPSSE staff will contact with administration information and questions.

First Name

Last Name

Title

Phone

Email Address

Secondary Contact
CIPSSE staff will only contact this person if the Primary Contact becomes unreachable.

First Name

Last Name

Title

Phone

Email Address

Mailing Address for CIPSSE Surveys
We will be mailing a box of surveys and instructions and will need an address for where to send it. We will additionally provide a return mailing label so that completed surveys can be returned to CIPSSE staff.

First Name

Last Name

Address Line 1 or PO Box

Address Line 2

City

Zipcode

Phone

Please indicate the number of surveys you would like to distribute to participating students. Note that we will send a corresponding number of consent statements to pair with the administered surveys.

Please indicate the number of administration instructional packets you would like us to send with the surveys. If one person will be administering all of the surveys, you will likely only need one instructional packet. If multiple people will be administering the surveys in different settings, you may want to request one packet for each administrator.

In order to participate in CIPSSE, CIPSSE staff need formal permission forms signed by both an official of the CIP program and the Department of Correction(s).

Note that we will not contact the Department of Correction(s) without permission from the Primary Contact for the CIPSSE administration. We will coordinate with the Primary Contact about how to proceed with attaining permission from the Department of Correction(s).

The following information is needed to complete this form before requesting a signature. You can see the form online here.

Department of Correction(s) Contact
We will not contact this person without first having a conversation with the Primary Contact above to coordinate contact.

First Name

Last Name

Title

Phone

Email Address

Please describe the CIP personnel who will be involved in administering the CIPSSE survey to students. With this description, please list the full name (first and last) of any personnel who will be administering the CIPSSE survey to students.

Please describe how students will be recruited for and communicated with about the CIPSSE study.

Please describe the setting where the survey will be administered.

Participation Agreement
Please review the CIPSSE Participation Agreement for details, including but not limited to CIPSSE procedures and safeguards, participating institution procedures and requirements, and use of CIPSSE data.

To confirm your registration, please agree to each of the following:

Agree: I have read and agree to the CIPSSE Participation Agreement

Agree: I verify, to the best of my ability, that the information entered above is accurate and up-to-date

After submitting this registration form, we will contact the Primary Contact to create a plan for requesting two signed permission forms: one from an official of the CIP program and one from the Department of Correction(s).