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.

Faculty/Staff Name:
Faculty/Staff Email Address:
Student Last Name:
Student First Name:
Course Name and Number:
Have spoken to the student regarding your concern(s)?
If no, why not?
Please check any statement that, in your judgment, describes this student: Student is not attending class
Student is continually late to class
Student is attending class but not making satisfactory progress
Student seems to lack Reading skills
Student seems to lack Writing skills
Student seems to lack Math skills
Student is not completing reading and/or homework assignments
Student appears to struggle to keep pace with the class
Student lacks aptitude in subject matter
Student is not participating in class
Student is not performing well on tests
Student exhibits poor attitude and/or disruptive classroom behavior
Other: please explain below
Please provide more detail on the selected item(s):
Would you like a follow-up email on the course of action this student agrees to take after he/she responds? Yes, I would like a follow-up
No follow-up necessary