Peer Review Consultation Sign Up Form

Name*
First Last
Email*
Department
Other Department*
Why are you requesting this Peer Review? (Choose all that apply)*
- Promotion & Tenure
- Academy of Teaching Scholars Completion
- General Teaching Improvement
- Other
Other*
Please describe the environment in which you will be teaching. (i.e. on rounds, in outpatient clinic, basic science online lecture, lab, grand rounds, etc.)*
Please describe the learners you will be teaching. (i.e. residents, medical students, graduate students, faculty, NPs, etc.*
Would you like to choose your consultant?*
- Any consultant would do
- I have a preference
Choose your consultant:*
Please provide three dates and times you might be able to meet with your consultant. The average lead time on scheduling peer reviews is 6-8 weeks. Therefore the dates provided should be no sooner than six weeks from today’s date. If you need your peer review to be conducted before the average lead time of six weeks, please fill out the form with the requested dates and follow up with an email to fapdd@iu.edu detailing your circumstance.
Date*
MM slash DD slash YYYY
Time*

: Hours

Minutes
Date*
MM slash DD slash YYYY
Time*

: Hours

Minutes
Date*
MM slash DD slash YYYY
Time*

: Hours

Minutes