ACADEMIC ALERT FORM

Please submit this form on any student who you feel needs to be contacted regarding excessive absences or other academic problems.
Mail form to: Gloria Montes, SFA 101 · Box 13072· gmontes@sfasu.edu · Extension 2188, Fax 7037

STEP 1 (Completed by Faculty Member)

Name of Student:_____________________________ID Number__________________

Contact Information if available: E-mail____________________Phone #______________

Course Name, Section Number: ___________________________________________

Major: ________________________

Reason for Referral:

Never attended class
Excessive absence
Poor performance on exams or class assignments
Assignments late or not complete
Lacking basic skills/background for this course
Study habits
Inattentive in class
Does not participate in class activities
Other (describe below)

Comments:

Referred by:_______________________________Mailing Address:_______________

Email address: ____________________________ Phone Number:________________

STEP 2 (To be Completed by Academic Alert Center)

Referred to: ____________________________________Referral Date: ___________
Additional Contact Information: ___________________________________________

STEP 3 (To be completed by Academic Alert Team Member & returned to Academic Alert Center)
Intervention Strategy and Response: ___________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Date Student Contacted:____________

STEP 4 (To be Completed by Academic Alert Center)
Date Reported back to Faculty________________________