Fillable CHEMISTRY LEARNING CENTER CHEM 103, 104 and 108 (University of Wisconsin - Madison)

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CHEMISTRY LEARNING CENTER CHEM 103, 104 and 108 (University of Wisconsin - Madison)

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CHEMISTRY LEARNING CENTER – CHEM 103, 104 and 108
Spring 2021
~Due to limited space, you may be placed on a waiting list~
Date
Name Student ID
Preferred Name Preferred Pronouns
(if any) (if any)
Email Cell/Local Phone
Please check
(
√) all that apply
CeO (TRIO) Scholar
Posse Scholar
Chancellor’s Scholar
First Wave Scholar
Badger Promise Recipient
Banner Program Recipient
On academic probation
First generation student
Transfer student (this semester)
CAE (Cntr for Acad. Excellence) Scholar
PEOPLE Scholar
Powers Knapp Scholar
Been away from sc
hool for
4
+ years
Bucky’s
Tuition
Promise
Recipient
FASTrack
Recipient
I am
re
-taking
th
is
c
hemistry
c
ourse
I have
a h
ard
time
u
nderstanding
E
nglis
h
Recent,
active,
full
-time
m
ilitary d
uty
Year: Fresh
Soph
Junior
Senior
Other
104
Course/Major Information
Major _________________________
Current chemistry course:
Instructor ____________________________
If the semester has started: Ex 1 Score ____
103
TA ____________________________
Letter Grade Ex 1 ____
Ex 2 Score ____
Disc Sec # ____
Letter
Grade Ex 2 ____
Previous course(s)
#Years of high school chem: ____ AP or IB chem?____
Last college chem course taken (if any): ________ Course Grade: ______ Year taken: _______
________ Course Grade: ______ Year taken: _______
Last college math course taken (if any):
#Credits this semester: ____
Current GPA (if any) ________
Heritage
1 2 2A 2B 3 4 5 6
Black Asian Cambodian Other Asian American Indian Hispanic Caucasian Other
Afro-American Laotian Pacific Islander Alaskan Latino
Vietnamese
Time Commitments (approximate hours/week)
Work: ____
Clubs/groups: ____
Athletics: ____
Volunteer work: ____
Family: ____
Other: ____
Previously enrolled in the Chemistry Learning Center? No Yes
, who did you work with? _____________
How did you hear about us? Friend
Instructor TA
Email Dean Advisor Web Walk-in
Other ___________
Were you referred to us? If yes, by whom _________________________________________________
***please complete the back of this page***
108
(
just numbers, no "-")
(
just numbers, no "-" or "( )")
CHEMISTRY LEARNING CENTER – CHEM 103, 104 and 108
Spring 2021
~Due to limited space, you may be placed on a waiting list~
extremely = 4
quite a bit = 3
Please circle a number for each statement:
moderately = 2
a little bit = 1
not at all = 0
1. I feel confident about taking chemistry. 0
1 2 3 4
2. I feel confident about doing math. 0 1 2 3 4
3. I feel confident about taking tests in general. 0 1 2 3 4
4. It is easy for me to ask for help. 0 1 2 3 4
5. I am good at memorizing things. 0 1 2 3 4
6. I am having personal problems that are interfering
with my ability to study. 0 1 2 3 4
****** Please complete these questions if the semester has already started ******
7. I am satisfied with the way in which I am being taught. 0 1 2 3 4
8. I can find time to study chemistry most days. 0 1 2 3 4
9. Chemistry seems to be taking up all my time. 0 1 2 3 4
10. I am thinking about dropping my chemistry course. 0 1 2 3 4
Please list each class you are taking as in “Chem 103” rather than writing an “X”; please include
work, research, or other time obligations; if these are flexible please note that; thanks!
Monday
Tuesday
Wednesday
Thursday
Friday
7:45-8:35
8:50-9:40
9:55-10:45
11:00-11:50
12:05-12:55
1:20-2:10
2:25-3:15
3:30-4:20
4:35-5:40
6:00-7:00
7:00-8:00
8:00-9:00
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CHEMISTRY LEARNING CENTER CHEM 103, 104 and 108 (University of Wisconsin - Madison)

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Completed 21 January 2021

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