From: Senja Putrisia Fajar Eldiningtyas <senjaputrisia@gmail.

com>
Date: 2018-03-23 11:23 GMT+07:00
Subject: Application for Use of Research Instruments (Theory of Planned Behavior-Based
Questionnaire)
To: dr335@medschl.cam.ac.uk

Surabaya, 11th May 2018

Name : Senja Putrisia Fajar Eldiningtyas

Institution : Universitas Airlangga Surabaya Indonesia
Departement : Nursing Departement
Address : Campus C Mulyorejo Street Surabaya (031) 595551
City/State/Zip : Surabaya East Java Indonesia 60161

Dear Sir

I am an undergraduate student from Universitas Airlangga writing my essay. I am a writing my

essay with title Analysis of Factors Affecting Family Behavior in Considering Post-Stroke
Patients at Home based on Theory of Planned Behavior, under the direction of my essay
committee chaired by Erna Dwi Wahyuni, S.Kep., Ns., M.Kep who can be reached at email :
rna.dewe@gmail.com as lecturer in Critical and Medical Surgery Departement, Faculty of
Nursing, Universitas Airlangga, Surabaya, Indonesia

I would like your permission to use the Theory of Planned Behavior-Based

Questionnaire/instrument in my research study. I would like to use and print your survey under
the following conditions:

1. I want to ask for the questionnaire document

2. I will use the surveys only for my research study and will not sell or use it with any
compensated or curriculum development activities

3. I will include the copyright statement on all copies of the instrument.

4. I will send a copy of my completed research study to your attention upon completion of the
study.

If these are acceptable terms and conditions, please indicate so by replying to me through e-
mail: senjaputrisia@gmail.com

Sincerely,

Undergraduate Student
Senja Putrisia Fajar Eldiningtyas
baiy@mail.montclair.edu
Validation of a Theory of Planned Behavior-Based Questionnaire to Examine Factors Associated
With Milk Expression

dr335@medschl.cam.ac.uk
Use of the Theory of Planned Behaviour to assess factors influencing the identification of
students at clinical high-risk for psychosis in 16+ Education