Center for Academic Excellence > Early Alert Program

Center for Academic Excellence
PO Box 1510
Pembroke, NC 28372

Phone: 910.521.6625
Fax: 910.775.4286
Email: cae@uncp.edu

Location: Jacobs Hall, Suite H
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early alert referral FOR INDIVIDUAL STUDENT

Please use this form to refer individual students. Complete the form and click the Submit button. Thank you!

1. Student's Name:

2. Classification

3. Student Phone (optional):

4. Student Address (optional):

5. Course:

6. Professor's Name (first and last):

7. Professor's Extension:

8. Please indicate with a check mark the factor(s), which you feel contribute to the problems (s) this student is experiencing and clarify in the Comments field. Information on specific attendance policies is helpful. Check = yes.

	FACTOR	COMMENTS

	Class Attendance

	Test Performance

	Class Participation

	Completion of Assignments

	Quality of Written Work

	Quality of Oral Work

	Content Difficulty

	Attitude

	Lack of Purpose/Motivation

	Personal Problems

	Social Interaction Problems

	Other

9. Has the student contacted you concerning his/her performance in class?

10. Would you recommend tutorial assistance for this student?

Specify (check all that apply): Content Writing Reading/Study Skills

11. Would you like a follow-up report from us?

Updated: Wednesday, August 6, 2008

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