Course Failure Impact Survey Form
Share how failing a course has affected your academics, motivation, and support needs.
Student Information
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Student ID
Academic Program / Major
*
Year / Level of Study
*
First Year
Second Year
Third Year
Fourth Year
Graduate
Other
Enrollment Status
*
Full-time
Part-time
Course Failure Details
Course Name or Code
*
Term/Semester When Course Was Failed
*
Please Select
Fall
Spring
Summer
Winter
Other
Was This Course Failed Once or Multiple Times?
*
Once
Multiple Times
Impact Survey
Emotional impact of the course failure
*
1
2
3
4
5
Academic impact of the course failure
*
Low impact
1
2
3
4
5
6
7
8
9
High impact
10
1 is Low impact, 10 is High impact
Areas affected by the course failure
*
Rows
Low
Moderate
High
Confidence
1
2
3
Motivation
4
5
6
Study habits
7
8
9
GPA outlook
10
11
12
Time management
13
14
15
Biggest challenge or support needed
Overall impact on your academic progress
*
Minimal
Moderate
Significant
Very significant
Other
Submit Survey
Should be Empty: