Student Feedback Request Form For Custom forms submit your request two weeks before your date of survey

1. Name	Phone #
Department	Email
2. Are you? (select one) Faculty TA	If TA, should a copy of the results be forwarded to TA supervisor? Yes No Supervisor's name
3. Course	Quarter and Year
4. Number of students in class	Have you used this service before? Yes No
5. Evaluation forms you wish to use: (Indicate the quantity of each form that you wil require) Standard form	Quantity Quantity Short Form Long Form TA Form GE class Lab Seminar Team teaching Studio
or Custom form Select items from the Custom Item List, and list their item numbers in your preferred order to the right: (We recommend selecting fewer than 20 items.) Custom forms should be submitted two weeks in advance.	1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
You may construct up to three (3) additional items for your custom form. (Please indicate order by assigning each an item number in the small box.)
6. Do you also want Comment Forms? Yes No
7. Date of survey
8. Questions or comments?