Request for Grade Review – Year 3 & 4 – Burrell College of Osteopathic Medicine Forms

Name:*
First Last
Date of Request:*
MM slash DD slash YYYY
Email:*
Enter Email Confirm Email
Class of:*
Course/Clerkship for which Grade Review is Requested:*
Course/Clerkship Director:*
Posted Score/Grade:*
Suspected Error:*
Description of Rationale for Request:*
Signature:
First Last
Date:*
MM slash DD slash YYYY
Time:*

: Hours

Minutes

AM/PM