Instructor’s Name:__________________________Student:_____________________________________ Student ID _______________Phone:_____________________________ E-mail ____________________ If you have taken any pre-emptive action(s) concerning this referral, please indicate by checking all that apply, and if applicable, add a comment concerning details or outcomes so far: Action Taken: □ Other (please comment) □ Written communication (note or letter) □ Individual conversation one-on-one □ □ E-Mail Phone call Comments:_____________________________________________________________________ Student needs assistance regarding: (Check all that apply) □ Deadlines missed Academic: □ Incomplete assignments □ Low Quiz/Test Score □ □ Missed Test Repeating Course □ Undecided Major □ Academic Integrity (cheating) □ Study Skills □ Time Management □ No textbook □ Tutoring . □ Never attended class Attendance: □ Excessive Absences □ At least one absence during first 2 weeks □ Student doing well then stops attending □ Tardiness □ Sleeping Classroom Behavior: □ Not taking notes □ Non-participation □ Inappropriate behavior □ Career *Personal Counseling □ Personal □ Difficulty processing information/assignments □ Financial □ Dependant care □ Illness □ Transportation Course Completion: □ Successful student has unexpectedly withdrawn □ Student withdrawn □ Instructor has initiated or is about to withdraw this student for reason noted below:
Instructor’s Name:__________________________Student:_____________________________________ Student ID _______________Phone:_____________________________ E-mail ____________________ If you have taken any pre-emptive action(s) concerning this referral, please indicate by checking all that apply, and if applicable, add a comment concerning details or outcomes so far: Action Taken: □ Other (please comment) □ Written communication (note or letter) □ Individual conversation one-on-one □ E-Mail □ Phone call Comments:_____________________________________________________________________ Student needs assistance regarding: (Check all that apply) Academic: □ Deadlines missed □ Incomplete assignments □ Low Quiz/Test Score □ Missed Test □ Repeating Course □ Undecided Major □ Academic Integrity (cheating) □ Study Skills □ Time Management □ No textbook □ Tutoring . Attendance: □ Never attended class □ Excessive Absences □ At least one absence during first 2 weeks □ Student doing well then stops attending □ Tardiness Classroom Behavior: □ Sleeping □ Not taking notes □ Non-participation □ Inappropriate behavior *Personal Counseling □ Career □ Personal □ Difficulty processing information/assignments □ Financial □ Dependant care □ Illness □ Transportation Course Completion: □ Successful student has unexpectedly withdrawn □ Student withdrawn □ Instructor has initiated or is about to withdraw this student for reason noted below: