UICOM - Chicago: Academic Learning Specialist Meeting Request Form

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UICOM - Chicago: Academic Learning Specialist Meeting Request Form

Please take a moment to complete this appointment request form. The Academic Learning Specialists/Academic Support Team wants to ensure that you are connected with all resources and support during your journey through Medical School. We will work diligently to schedule all students who fill out this form.

**Please note that all requests are handled in the order they are received. We try not to have a waitlist for any student who would like Academic Support but sometimes this cannot be avoided. We hope to be able to schedule all meeting requests asap, but please know that your meeting may be one to two weeks out from the time you fill out this form. Thank you!

Email *

Your Name (First and Last) *

UIN *

Name of PHA? *

Name of OSA - Lead? *

Anna Reczynski

Sue Anne Tae

Noreen Abbasi

Greg Bailey

Year in Medical School *

Other:

Required

Type of Request *

M1 Blocks

M2 Blocks

Step 1

Step 2 CK

Other

Are you actively working with a Peer Educator at this time? *

Yes

I was but I am not longer meeting with a PE on a regular basis

If you are actively working with a Peer Educator, who is the PE? If not working with a PE please write NA. *

Do you work with your PE 1-1 or in a small group? *

1-1

Small Group

When would you like to meet? Please list 2-3 dates/times that will work for you in the next two weeks. Most meetings are 30 minutes in duration. *

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