Academics

• Your Name*
• Student ID*
• Phone Number*
• Email Address*
• Campus Address*

Please answer the following questions completely (and truthfully!)

Class in which you need assistance

• Class Name*
• Faculty email*
• Are you attending class regularly?* Yes No
• I have completed % of the reading.*
• I have completed % of the homework.*
• If you are not attending class regularly, please explain why.
• Briefly describe what you see as hindering your progress in this course. Please be as specific as possible.
• Are there any additional situations or conditions that may be related to your performance in this course (i.e. a learning disability, etc.)?