Please submit this form on any student who you feel needs to be contacted regarding excessive absences or other academic problems. The information will be emailed to Gloria Montes after you click the submit button.

Completed by Faculty Member

Name of Student:
ID Number:
Course Name, Section Number:
Student's Email Address (if known):
Student's Local Phone (if known):
Student's Major (if known):
Reason for Referral: Never attended class Excessive absence Poor performance on exams or class assignments Assignments late or not complete Lacking basic skills/background for this course Study habits Inattentive in class Does not participate in class activities Other (describe below)
Comments:
Faculty Member:
Faculty Email Address:
Faculty Phone Number:
Faculty Campus Mail Address:

A team member will be assigned to contact the student. The student will be counseled regarding the problem or referred to other services, if needed. The team member will report back to the program coordinator and the coordinator will report back to the faculty member. Thank you for your continued interest in student success!