Years 3 and 4 Grade/MSPE Appeal Request Form

If a student believes that they have been awarded a final grade for a course* that does not adequately represent their performance in the course*, the student may appeal the grade under the procedures described in the Student Progress Committee Procedures and Process for Dismissal Policy. Per policy, appeal requests must be submitted within 10 working days of receipt of the final grade form.

Upon course* completion, the student should have no further communication with the clinical site faculty regarding the assigned grade. Students should not request any involvement from a third-party in the grading decision. Should a student fail to abide by this they may be issued a Level 1 under the domain of Professionalism.

Course* = Any component of the curriculum where a grade is earned.

Student Info

First Name *

Last Name *

Year where the assessment was assigned: *

Year 3

Year 4

UA Email Address: *

Are you submitting a grade appeal or a narrative assessment/MSPE appeal? If you are submitting both a grade and narrative assessment appeal, please submit two separate forms. *

Grade

Narrative Assessment

Impacted Curriculum

Third Year *

Fourth Year *

Site Name: *

Course code: * 🛈

PPD Semester *

Date the grade was assigned: * +

Basis of MSPE Narrative Assessment Appeal

Please describe the nature of your narrative assessment (Dean's Letter/MSPE) appeal including the specifics around feedback that should or should not be included. *

Please list the full names of individuals who you feel are best poised to substantiate your appeal. Please include contact information (phone numbers, emails) when possible. * 🛈

Basis of Grade Appeal

Please select the basis for your clerkship grade appeal (select all that apply) *

Error in score transcription or mathematical calculation

Appeal of grading in ‘other score’

Appeal of overall grade

Appeal of clinical score

Please select the basis for your selective grade appeal (select all that apply) *

Error in score transcription or mathematical calculation

Appeal of grading in ‘other score’

Appeal of clinical grade

Please select the basis for your LIC grade appeal (select all that apply) *

Error in score transcription or mathematical calculation

Appeal of grading in ‘other score’

Appeal of specialty grade

Appeal of overall LIC grade

Appeal of clinical score

Please select the basis for your elective grade appeal (select all that apply) *

Appeal of overall grade

Please select the basis for your course grade appeal (select all that apply) *

Appeal of overall grade

Please describe the nature of your appeal. Note that a single example of exceeding expectations would not typically be considered sufficient to justify an overall summative grade of exceeding expectations. *

Please describe the nature of your clinical grade appeal. Please organize your appeal by specific Educational Program Objective (EPO), stating both what you were assigned on the EPO and what you feel it should have been. Each EPO being challenged should be organized into its own section (e.g., paragraph, bullet point). In your supporting narrative, please justify each EPO appeal by describing a pattern of consistent performance to justify your claim. You may want to focus on the behavioral anchors associated with each EPO to guide your narrative response. Please note that a single example of exceeding expectations would not typically be considered sufficient to justify an overall summative grade of exceeding expectations. * 🛈

Please list the full names of individuals who you feel are best poised to substantiate your appeal. Please include contact information (phone numbers, emails) when possible. If appealing the mathematical calculation only, put "N/A". * 🛈

(Optional) You may upload supporting documents, if available:
Do NOT upload any medical records or protected health information.

Ambulatory Elective	Elective
Family Medicine Clerkship	LIC - Longitudinal Integrated Clerkship
LPC - Longitudinal Patient Care	Medicine Clerkship
Neuro Clerkship	Obstetrics and Gynecology Clerkship
Pediatrics Clerkship	PPDA
Psychiatry Clerkship	Surgery Clerkship

Ambulatory Elective	Elective
Family Medicine Clerkship	LIC - Longitudinal Integrated Clerkship
LPC - Longitudinal Patient Care	Medicine Clerkship
Neuro Clerkship	Obstetrics and Gynecology Clerkship
Pediatrics Clerkship	PPDA
Psychiatry Clerkship	Surgery Clerkship

Critical Care	Elective
Emergency Medicine Clerkship	PPDB
Sub-Internship

Critical Care	Elective
Emergency Medicine Clerkship	PPDB
Sub-Internship