Early Alert Form

NOTE: The Early Alert Form can ONLY be submitted to Student Support Services (SSS) AFTER the instructor has held a conference with the student.

Student's Information

Student's Name (Required)

Student's Cell # (Required)

Student's Home # (Required)

Student's Home address (Required)

Student's Email address (Required)

Course (Required)

Instructor (Required)

REASONS/ISSUES/CONCERNS FOR REFERRAL(Required):

This student is being referred to Student Support Services for the following academic and/or life issue(s):

 Reading skills Study skills Writing skills Math skills Child care problems Transportation problems Health problems Late or absent from class Personal problems Financial problems Computer skills Off-Campus Work Issues Research skills

OTHER REASONS/ISSUES/CONCERNS AND/OR FURTHER INFORMATION:

Student is currently PASSING this course (Required):

 Yes No

Attendance

 Not attending Tardy Not logged into course (if applicable)

Poor academic performance

 tests, quizzes, and/or papers

Class participation

 student is NOT engaged in class discussions or assignments

Actions Taken (Required):

Please describe the steps you have taken to assist the student:

 Talked about study skills, test prep, etc. Met with student during office hours Referred student for tutorial services Referred student for counseling services None of the above

ADDITIONAL INFORMATION:


Be sure to notify the student that you are referring him/her for assistance.
Special Note: To facilitate contact of the student, be sure to include as much of the above requested student contact information as possible.

TO THE INSTRUCTOR (Required):

I have talked with the student about the issue(s) that is (are) presented here. I have also notified the student that I am referring him/her to Ms. Sandra Copeland, the Student Support Services (SSS) Counselor, for assistance and that he/she can expect to be contacted by Ms. Copeland concerning this report.

 Yes No

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