Early Alert Form

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NOTE: The Early Alert Form can ONLY be submitted to Student Support Services (SSS) AFTER the instructor has held a conference with the student or attempted some form of contact with the student via phone, email, text, etc.

Student Information

Student Name (required)

Student ID # (required)

Phone # (required)

Home address (required)

Your Email (required)

Course (required)

Instructor (required)

Concerns

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 Research skills

For Students In Online and Hybrid Courses

Did student enter the course in a timely manner?
 yes no

Does student “go into/visit” the course on a regular basis?
 yes no

Is student completing and submitting assignments by due dates?
 yes no

Is student submitting work that is thorough and appears to reflect effort in the development and completion of the work?
 yes no

Is student completing tests in a manner that is in keeping with guidelines and deadlines?
 yes no

Other

Actions Taken

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

Talked about study skills, test prep, etc.
 Yes No

Met with student during office hours
 Yes No

Describe all attempts to contact/communicate with the student.

Referred student for tutorial services
 Yes No

Referred student for counseling services
 Yes No

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.

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