Qualtrics Survey | Qualtrics Experience Management

Feedback for Promotion and Advancement: Request Form for Historical Individual Teacher Assessment Reports (UGME)

Per the (022) Assessment of Teachers by Students Policy, upon request, Individual Teachers (or their designate) or Department/ Division Head (or their designate) can request historical individual medical student feedback on teaching reports (UGME) for promotion, advancement or awards.

Please note that the standard turnaround time for report requests is approximately 10 business days. For urgent requests, please include relevant details in the notes section and efforts will be made to accommodate the timeline.

Note: Report requests for awards
Given the limitations and potential biases in the literature around student evaluation of teachers, we want to highlight that this information should be considered supplementary support in the adjudication of awards or teacher recognition, and recommend that it not be relied upon as the sole source for decision-making.

Are you requesting a report for yourself or someone else?

Myself
Someone Else

Myself:

1. First and Last Name:

2. Email:

3. Time span of Report- Start Date: (mm/dd/yyyy)

4. Time span of Report- End Date: (mm/dd/yyyy)

5. Purpose of Request:

Someone Else:

1. Your name:

2. Your email:

4. The first and last name of the teacher/ faculty:

5. Time span of the report- Start Date: (mm/dd/yyyy)

6. Time span of the report- End Date: (mm/dd/yyyy)

7. Purpose of request:

8. I confirm that I have been authorized by the above stated faculty (as their designate) to make this request and have access to their report: (Yes/No)

9. Name of person who authorized the request: Department/ Division Head or Individual Teacher Name

10. Who the report is being released to: Name(s) & email(s)

9. Additional notes (ie. date of when you need the report by?):

5. Should this report be released to anyone else in addition to yourself?

Yes
No