Academic Referral Form
Last Name of Student being referred:
First Name of Student being referred
Faculty member making the referral:
Faculty member's email
Faculty member's phone number
Preferred method of contact
Phone
Email
Course Name and Section Number
Please tell us why you are concerned about this student's progress or performance in your class.
- I am concerned about the student’s attendance record
- Student has had difficulty gaining access to relevant course materials, such as readings and lab supplies
- Student has difficulty gaining access to relevant course technology
- Student has difficulty learning to use to relevant course technology
- Student needs support with academic research or other Library resources
- Student participation in class discussion is well below average
- Student performance on early quizzes, exams or other assignments is well below average
- Student is having difficulty understanding, retaining, or recalling information from course readings and lectures
- Student is having difficulty managing tasks/assignments and meeting deadlines
- Student is having difficulty with multiple aspects of learning in my course
- Student disclosed a disability and is not sure where to go for help
If there is any other relevant information about the student’s performance that you would like to share, please do so in the space below.
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