Early Alert
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1.
I am:
--None--
Faculty
Staff
Student
2.
Name:
*
3.
Email:
*
4.
If your concern relates to performance in a course, please specify Course Title and Number:
NOTE:
Only one student per form to preserve confidentiality.
5.
Student Name:
6.
Academic Concern (check as many as apply):
Student seems to lack Reading skills
Student seems to lack Writing skills
Student seems to lack Math skills
Student is not utilizing approved recommended accommodations
Students is attending a class but is not making satisfactory progress
The student is not attending class
The student peforms poorly on quizzes and/or exams
The student is not particpating in class
The student is having difficulty completing assignment, (Student is turning in assignments late)
The student's performance has dropped; the quality of the student's work has diminished
The content of the course appears to be difficult for the student
The student has not accessed course materials (syllabus, assignments) on the course Moodle site
Other, please specify
7.
Personal (check as many as apply):
The student is demonstrating a poor attitude
The student appears to have problems interacting socially
The student apppears to have personal problems
The student has demonstrated problems adjusting to college life
The student is showing signs of depression, sadness, loneliness, homesickness
The student's physical appearance has drastically changed
Other, please specify
8.
Please describe what has already been done to address the problem and person involved:
9.
Please discuss the referral with the student and provide a brief description of the communication:
Disclosure:
In accordance with the Family Educational Rights and Privacy Act (FERPA), the system is designed to allow referrals to be viewed only by those individuals who have a need to know. The information shared will not become part of the student’s permanent record. In addition, state and federal privacy laws prohibit the unauthorized disclosure of personally identifiable health information.