Faculty/Instructor Dialogue Request Form

Your Name: *

Your Email: *

Your Phone Number: *

School/College *

Campus Department/Unit *

Department or Unit Program Assistant/Coordinator

Department or Unit Program Assistant/Coordinator Phone

Course Number and Name (e.g. Hist 1015: US History to 1885) or Event Title:

Date

Month

Day

Year

Time

Hour

Minute

Building & Room Number:

Expected Attendance:

Reasons for dialogue request: (mark all that apply)

To create a memorable learning experience for students

To extend student learning about a particular course topic/concept

To present students with perspectives on a topic that they would not otherwise hear

To address a controversial topic or complex issue that cannot easily be addressed through regular class discussion

To learn about dialogue as a pedagogical tool to use in my own teaching

What topic(s) would you like to address in the dialogue?

What are some specific questions you would like to address in the dialogue?

List your key learning goals (outcomes) for hosting a dialogue in your course. Please explain how and to what extent they align with course goals.

Would you like assistance in creating follow-up materials to use in your class after the dialogue?

Yes

Would you like any other form of assistance or to meet with the CU Dialogues Program Coordinator/Facilitator before setting up a dialogue?

Leave this field blank

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