With this information, we can contact the student and encourage participation in student
programs, tutorials, counseling, and/or workshops that may help the student academically or
personally. Information you provide may be shared with the student, who has legal access to this
information. Observations should be objectively stated.

Referred by Faculty/Staff:

Faculty/Staff Email:

Student's Name:

Course/Extracurricular Activity:

Date:

Have you personally contacted and met with this student?
Yes No

If yes, what was the date?

Attendance - dates missed and reason (if known):

Areas of concern

Classroom Behavior
Poor Academic Performance
Failure to turn in assignments
Indicated they will not be returning next semester
Changes in appearance/personality
Other (Please explain)