Dept. Head (or designee)____________________________ Phone________
 
        Department_______________________________ Date Submitted  __/__/__

        Number of questions ____                  Date Completed  __/__/__

        Evaluations requested (Check all that apply)                      

        ___ FULL - produce a report for each section.          Copies____ 
 
        ___ DEPARTMENT - produce an overall report for the           ____
                         department, combining all sections.              

        ___ COURSE - produce a report for each course, combining     ____
                     sections within each course.                         

        ___ TEACHER - produce a report for each teacher, combining   ____
                      sections taught by each teacher.                    

        Enter question subgroupings below - 20 subgroupings maximum.

         1: ____-____             11: ____-____

         2: ____-____             12: ____-____

         3: ____-____             13: ____-____

         4: ____-____             14: ____-____

         5: ____-____             15: ____-____

         6: ____-____             16: ____-____

         7: ____-____             17: ____-____

         8: ____-____             18: ____-____

         9: ____-____             19: ____-____

        10: ____-____             20: ____-____

Special requests: