FIU-HWCOM-ACES Supplemental Peer Instruction Request Form

Directions:
1. Please complete the request form below and submit in order to request 1-to-1 peer tutoring services.
2. Ensure that you have read the policies and procedures below regarding peer tutoring sessions.
3. Once your form is complete, you will be asked to sign confirming that you have read and agree to the FIU-HWCOM ACES (formally SASS) Peer Tutoring policies and procedures.

Name Name First Last
Phone Phone - ### - ### ####
Panther ID
FIU Email Address
Academic Rank

Academic Rank M1 M2 M3 M4
Which of the following Student Academic Success Services have you used?

Which of the following Student Academic Success Services have you used? Small Group Tutoring Peer Advice Panels Resource Guides Academic Enrichment Consultant Virtual Study Rooms ACES Led Workshops None
How did you hear about the FIU HWCOM ACES Supplemental Instruction Services Program?

How did you hear about the FIU HWCOM ACES Supplemental Instruction Services Program? OSA Academic Advisor Faculty Member FIU HWCOM ACES Staff Self-Referral Other (Please specify) Other (Please specify)
Please check off the class(es) for which you are requesting a tutor.

Please check off the class(es) for which you are requesting a tutor. Genes, Molecules, and Cells Structure of the Human Body Integrated Functions of the Human Body Pathology and Infectious Disease Pharmacology Clinical Epidemiology and Quantitative Research Cardiovascular and Respiratory Systems Hematopoietic and Lymphoreticular Systems Integumentary System: The Skin Musculoskeletal Systems Gastrointestinal System and Medical Nutrition Endocrine System Reproductive System Renal System Nervous System and Behavior I Nervous System and Behavior II STEP Sucess Program-M2
Please provide your most recent course Midterm/Final Grade (In-house & NBME)
For all selected, please advise as to whether you are currently taking or remediating the course?
Have you previously failed any courses?

Have you previously failed any courses? Yes No
Please check off the class(es) for which have failed

Please check off the class(es) for which have failed Genes, Molecules, and Cells Structure of the Human Body Integrated Functions of the Human Body Pathology and Infectious Disease Pharmacology Clinical Epidemiology and Quantitative Research Cardiovascular and Respiratory Systems Hematopoietic and Lymphoreticular Systems Integumentary System: The Skin Musculoskeletal Systems Gastrointestinal System and Medical Nutrition Endocrine System Reproductive System Renal System Nervous System and Behavior I Nervous System and Behavior II
Please check all items that best describe how you would like a peer tutor to assist you:

Please check all items that best describe how you would like a peer tutor to assist you: Understanding course concepts Practice problems and non-graded homework Test preparation Study skills and resources
Please provide us with any information that will help us find the best peer tutor for your needs (i.e.- prefer weekend hours, or someone who can do late nights).
Tutee Procedures and Policies
Please sign to acknowledge that you have read and reviewed the ACES (formally SASS) Tutee procedures and policies above the signature field of this form.

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FIU-HWCOM-ACES Supplemental Peer Instruction Request Form

FIU-HWCOM-ACES Supplemental Peer Instruction Request Form

Tutee Procedures and Policies