• Professor Name:
• Professor Email Address:
• Name of Student Being Referred:
• Email address of student being referred:
• SID:

  This is the the Student Identification Number

• CRN: (class enrolled in)

• Referral for Academic Performance:

• Student Requires support in the following areas: note taking time management test taking failed exam, quiz missing / incomplete assignments

  Select all that apply

• Additional Comments / Recommendations:

  Please provide us with any additional information you feel appropriate

• Referral for Attendance Issues:

  FIRST WEEK of classes: Due to frequent schedule changes, please do not send EAs
  SECOND WEEK of classes: Please monitor attendance closely and begin sending EAs
  REMAINDER OF THE SEMESTER: please send EA only after you have attempted to contact the student first

• Student has never attended class: check if applies
• Student attended class regularly until (fill in date in fields provided) but now is missing class more often than s/he attends / MM / DD YYYY
• Student has missed class multiple times and it is affecting his/her grade (fill in number of times in field provided below)

• I have attempted numerous times to contact the student by:

• Select method(s): Phone student's campus email address student's personal email address
• Indicate total number of times:
• Did you receive a response? Yes, the student responded No response from student
• If you received a response, please describe:
• Additional Comments/Recommendations:

• *** Please use this form only when other options have been exhausted ***

Referral for Behavioral Concerns:

If this is an emergency, dial 911!

To have dispatch get an officer (24/7), please dial 589-5807.

To talk with ASU Police Department office personnel, please dial 587-7901.

For the following non-emergency behavioral concerns:

• Students attitude and/or behavior is disruptive in the classroom
• Comments of concern from other students
• Change in demeanor and/or physical hygiene (i.e. anxiety, aggression, depression, appears tired constantly, has difficulty staying awake)

Contact Student Affairs directly at klmarque@adams.edu

Referral for Personal Issues Affecting Student:

For the following:

• Health issues
• Relationship issues

Contact Student Affairs directly at klmarque@adams.edu

For the following:

• Financial issues

Contact Financial Aid directly at ascfa@adams.edu