Student-Community Engagement Reporting Form

Please use this form to tell us about your community engagement efforts, including community-based research, course activities, and media coverage. If you have any questions, please contact dei-pharm@uic.edu.

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Name of the person submitting the report? * Required
Student Organization or Course Name/Number (Please enter "N/A" if this effort is not tied to an organization or course): * Required
Event/Engagement Name: * Required
Co-sponsors/partners: * Required
Event Date(s) (MM/DD/YY): * Required
Event start and end time(s): * Required
Event Location: * Required
Number of student participants: * Required
Number of constituents/community members served: * Required
Please describe the populations served (Hispanic/Latinx/o/a, African American, veteran, elderly, low-income, immigrant, LGBTQIA, etc.): * Required
Please describe the event/engagement goals: * Required
Please describe the impact your efforts have had on the community/ies served: * Required
Please provide at least one testimonial from a community member served: * Required
Please provide at least one testimonial from a student participant about the experience and the impact of the project/event: * Required
Please share a fun/poignant anecdote or story from the event/engagement: * Required
Please upload at least one photo from the project/event. (maximum file size: 50MB) * Required
Max. file size: 15 MB.

Retzky College of Pharmacy - Chicago | Rockford

Student-Community Engagement Reporting Form

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Chicago Campus

Rockford Campus

Student-Community Engagement Reporting Form

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