Student Status/Referral Form

Student Name:


Course Name/Number/Section:

Faculty Member:     Phone:

Faculty Email:

My records indicate that the student's work is unsatisfactory due to:

Academic difficulty    Non-attendance    Irregular class attendance

Interferance due to physical disability    Suspected learning disability    Other


I have contacted this student and recommended the following course of activity:

Counseling    Return to class     Tutorial assistance

Withdrawal before deadline    Other

Please specify if other :

This section for counselors only:

Student Telephone:     Advisor:

Counselor Comments :

I have been unable to contact this student