CHEM 272 Sample Data Request Form

Student Name: _______________________________________________________

Email address: _______________________________________________________
Section # (or day and time): ____________________________________________
Teaching Assistant: ___________________________________________________
I am requesting sample data for:

Reason you are requesting this data. You must include appropriate written
documentation.

I affirm that the information I have provided in this request is correct and
understand that providing false information in this request is an honor code
violation and could result in a grade of XF.
Student signature: ___________________________________________________
Date: ______________________________________________________________
1. Bring this completed form to Dr. Houck in CHM 1102B.
2. If the request is approved, you will receive an email from the instructor along with
sample data.
3. Sign up for a make up quiz (10 points) at
http://portal.chem.umd.edu/undergradoffice/ (Quizzes are given on Friday
mornings at 7:30 am. Note the examination date when you sign up.)
4. Be sure to submit a hard copy of the sample data along with your lab report to
your TA when you hand the lab in.
5. Be sure to clearly indicate on your report somewhere that you are using sample
data.