EARLY ALERT/INTERVENTION PROGRAM REFERRAL FORM
By providing 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. The information you provide here may be shared with the student, who has legal access to this information. Observations should be objectively stated.
FACULTY/STAFF EMAIL:
FACULTY/STAFF'S NAME:
OFFICE PH #:
STUDENT'S NAME:
DATE:
STUDENT'S BSID:
COURSE:
PLEASE CHECK ANY STATEMENTS THAT, IN YOUR JUDGMENT, DESCRIBE THIS STUDENT:
Student is not attending class
Student is attending class but not making satistactory progress
Student is not completing reading and/or homework assignments
Student is not participating in class
Student is not performing well on tests
Student lacks essential skills
Student exhibits poor attitude and/or disruptive classroom behavior
Other: Please Explain
Clarification of items checked above: