Student Early Alert System Form | Online Forms | Paine College

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	Student Early Alert System Form Thank you for identifying a need to assist and support one of our students. This Early Alert form has been provided to faculty members as a mechanism to help students. General Education Development Center (GEDC) will forward all sophomore, junior, and senior student notifications from faculty to The Counseling and Wellness Office for student intervention. If the faculty member feels that a student is in a compromising or emergent situation, please contact the Paine College Office of Security at 706-821-8235. Please complete ALL student contact information before referring. Student Information Last Name: * First Name: * Student ID Number: * Email Address: * Commuter Status: * Residential StudentCommuter Student Classification: * FreshmanSophomoreJuniorSenior Faculty Member Information Last Name: * First Name: * Email Address: * Office Location: * Telephone #: * Course #: * Course Title: * Observed Issues Please identify issues that you have observed with students in the categories below. Check one or all that apply: Academic Disruptive in class Poor academic performance Failure to submit assignments Not attending class Request academic advising Number of absences: Academic Skills Deficiencies Reading skills Research/documentation skills Writing skills Failure at multiple assignments Personal Family/friend death Financial problems Family/personal crisis Social Continual isolation Relationship problems Violence Race based issues Roommate tension Please answer the following questions and be as detailed as possible. Have you already made an attempt to address your concerns with the student (i.e. email, telephone call, personal conference)? * Is this your first time referring this student? If not, please share of other referrals you have made for this student? * At this point in the semester, do you believe that it is still possible for the student to be successful in this course? Explain? * Please describe the students’ academic performance in the course thus far (i.e. grades on tests, assignments, absences, tardies, etc.)? * What is the desired result of this referral? * Additional Comments: Need assistance with this form?