Center for Academic Excellence

Student's Information

*Last Name:

*First Name:

Middle Name:

Classification: Select Classification --->> Freshman Sophomore Junior Senior Not Sure

*Banner ID:

Email:

Phone:

Course Information

*Course #:

*Section #:

*Your Name:

*Your Phone:

*Your Email:

*Date:

Factors

Please check the appropriate boxes below to indicate the * factor(s), which you feel contribute to the problem(s) that the student is experiencing, and provide detailed information in the Comments field. Information about special attendance policies is helpful.

To select multiple factors, hold down the Ctrl (Windows) or Command (Mac) key.

*Factors
Class Attendance Quality of Written Work I.T. Skills Test/Quiz Performance Quality of Oral Work Personal Problems Class Participation Content Difficulty Social Interaction Problems Completion of Assignments Attitude/Lack of Purpose/Motivation Other

Comments and Prior Outreach to Student :

Specify the Area - To select multiple factors, hold down the Ctrl (Windows) or Command (Mac) key.:
Content Writing Reading/Studying Skills IT Skills