Thank you for visiting the Department of Ophthalmology and Visual Sciences and the Illinois Eye and Ear Infirmary at the University of Illinois at Chicago! We are grateful for your company, and would appreciate you letting us know about your visit.

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* 1. Last Name

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* 2. First Name

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* 3. Your Information

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* 4. Your Organization or Institution

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* 5. Primary Host or Mentor at UIC

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* 6. Primary Specialty at UIC

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* 7. Start Date of Visit or Training at UIC

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Time

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* 8. End Date of Visit or Training at UIC

Date
Time

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* 9. What did you enjoy about your experience at UIC?

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* 10. What would have improved your experience at UIC?

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* 11. Comments/Additional Notes

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