SYSTEM-WIDE NOTE-TAKER FEEDBACK FORM
Please return the completed form to the Office of Accessibility.
Note: If you are experiencing issues with your notes in more than one class, please fill out a form for each class.
TO BE COMPLETED BY STUDENT
Today’s Date: ________________________
Student Name:____________________________ Student ID Number: ____________________
Telephone Number:__________________________ E-mail Address: _____________________________________
Course Number:______________________ Class Dates:___________________ Class Times:_________________
Next exam date:_________________________________________
Student Signature: _______________________________________
CHECK ONE OF THE FOLLOWING:
_____ I am currently not receiving notes. Please provide the date when you stopped receiving notes: __________
_____ I am not satisfied with the quality of notes. Please explain why you are not satisfied with the quality of notes.
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FOR OFFICE USE ONLY
Note-taker Name:_____________________________________ E-mail Address: ____________________________
Telephone Number: __________________________________
Date contacted: __________ Method of Contact:___________
Staff Initials:_________________________________________
RESULTS
Notes brought in: Yes or No If yes, date received ________
New Note-taker assigned: Yes or No New Note-taker Name:__________________________________
New Note-taker contact information:_______________________
Notes:
1/2016