Date: _________________________

To: __________________________________________ Dept:_______________________

Address: _____________________________________ Phone: ________________________

From: ___________________________________________ Disability Services, 12 Johnston Hall;

Phone: _______________________________

Regarding: ________________________________________ ID #: ________________________

Student name 

Student signature: ______________________________________________________

The above student has asked that you provide information relevant to his/her learning and performance in your classroom. The Council on Liberal Education will use this confidential information when determining whether the UMTC Liberal Education (LE)requirements should be modified for the student. Your input is important and appreciated. Please return this form to the Disability Specialist at the above address.

1. Please list the course(s) in which the student was enrolled with you.

____________________ _________________ Yes/No __________________ _______

____________________ _________________ Yes/No __________________ _______

Course Term/Year      Course Completed? If no, date of withdrawal. If yes, grade

2. The student's attendance was: Regular, Sporadic, Poor

3. Please comment on the student's class participation.

4. Describe the amount of contact you had with the student outside of class (e.g., office hours, tutoring, labs).

5. Did the student receive tutoring through your department? (Yes/No) If yes, what was the impact of the tutoring?

6. How did the student perform (grades) in the following areas (include written and oral participation)?

Homework: _____________________________________________________________________

Quizzes: ________________________________________________________________________

Tests: __________________________________________________________________________

7. What strengths did the student bring to your class?

8. What weakness were evident in the student's study of your subject?

9. What other comments could you make about the student's abilities and efforts in your course(s) that would help determine whether the UMTC LE requirements should be modified?