Learning Environment Feedback Form

Learning Environment

Feedback Form

Email address*

Your identity and the report will be handled confidentially and will be protected unless it is required by law or University policy.

*Click "send me a copy of my responses" to ensure you will receive an email confirmation.

Type of feedback*

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Exemplary professional behavior

Exemplary professional behavior embodies a welcoming climate for learning that enhances satisfaction, well-being, academic performance, and collaboration. Exemplary professional behavior can be noted for an individual, site, or overall educational experience.

Date of the event (optional)

What is your involvement in this experience?*

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Name of the person this feedback is about*

Role of the person this feedback is about*

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Where in the curriculum did this experience occur?*

(Block, Course, Clerkship, etc.)

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Clerkship

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Elective

Course (Longitudinal)

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Preclerkship

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Selective

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Site or location*

Provide the name of where the event occurred.

Description of exemplary professional behavior*

Learning environment concern type:*

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Explanation of learning environment concern*

We recommend you discuss this situation with Jane Korn, LEO Consultant, who is experienced in assisting students with addressing concerns in the learning environment. Discussing this further may not only help you but may help to improve the learning environment overall. Are you open to discussing your concern further using this confidential resource?*

Yes

Submission number*

Create a submission number and save it for future reference. This number will be the identification number for your feedback.

Example - a family member's birthdate or digits from an old address, something only you know and can recall. Be mindful to not use information, such as your current phone number or your own birthdate, which might identify you as the reporter.

Is there anything else you'd like to add? Optional

Send me a copy of my responses

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