This is a sample form (provided by the CS Mental Health Committee) that faculty and course staff can use to create their own forms to share with their class as a way of collecting feedback and checking in with the students.

Courses may use this form for inspiration or by making a copy of the form on Google Drive. We highly encourage making this form open for anonymous submissions so students can be more transparent with their responses. If you will be collecting emails or identifying information, please be sure to disclose that to students beforehand.

[Note: This sample form is meant as a reference and is not monitored for responses. If you have questions, feel free to email us at illinois.csmhc@gmail.com]