Office of Student Success and Retention

Student’s Name______________________________________________________

Classification of student, if known: (please circle) Sr. Jr. So. Fr.

Student is having difficulty in ___________________________________________

Student is experiencing problems regarding:

_____Excessive absences (please circle) 1-3, 4-6, more than 6

_____Lack of participation in classroom activities/discussions

_____Decline in quality of work

_____Failure to complete assignments (please circle) occasionally, all the time

_____Failure to complete assignments on time (please circle) occasionally, all the time

_____Attitude

_____Low test scores

_____Missed tests and/or exams

_____Reading/Writing/Math Skills

_____Other reasons for concern (financial, health, personal, etc.) Please contact me personally.

yes no - In your opinion would a tutor be beneficial to this student?

By providing this information we can contact the student and encourage participation in student support programs.

Name of person making referral:_________________________Date:____________

Department_____________________Phone #___________________

Attempted intervention:

Have you talked with student about the problem?

Comments:

Please return to: Nancy Callis
Office of Student Success and Retention
Room 318 Hyde Hall (top floor) or place in my box in Varnell-Jones Hall
Phone # 425-3228
Email: callis@lambuth.edu