CLT Form

Mid-semester Feedback on Instruction

Please make sure to fill in all relevant fields so that we can process your request.

**N.B. : You need to contact CLT to agree on survey questions.

Name :

Email address :

Office phone number :

Department

Type of mid-semester feedback requested

Mid-semester survery online via WebCT (in class)
Mid-semester survey online via WebCT (out of class)
Mid-semester survery via Clickers (with an option to include open-ended questions)

Small Group Instructional Diagnosis (SGID)

How many classes would you like to conduct the survey for?

one two three four

Do you wish to use the same survey questions for all classes?

Yes

No

Questions relevant only for in-class surveys and SGIDs:
Note: Please skip to question 7 if your students will take the survey via WebCT from home(out of class).

Please provide detailed class information and the preferred date for conducting the survey. CLT will schedule the survey on your preferred date and time whenever possible.

Class Sec WeekDays Time Location Number of Students

Preferred Time : WeekDay Day Month

Class Sec WeekDays Time Location Number of Students

Preferred Time: WeekDay Day Month

Class Sec WeekDays Time Location Number of Students

preferred Time: WeekDay Day Month

Class Sec WeekDays Time Location Number of Students

Preferred Time: WeekDay Day Month
The Survey/SGID takes around 20 minutes. You prefer that your students take it:
At the beginning of class

At the end of class
If you wish to post the survey on WebCT to be taken by students from home please specify the following:
Survey should be available starting:

Day Month Hour Min AM/PM

Survey availability should end on:

Day Month Hour Min AM/PM
Other Requests or Remarks

Thank You

Falaki Academic Center (FLAC)

Rooms 212A and 212B

Tel. 20.2.797.6659, clt@aucegypt.edu