Referral


Instructions:

Please indicate the issues that concern you about this particular student. Note, you may answer as few or as many questions as you like.

 
YesNoDon't Know
Showing abrupt change in academic engagement and/or overall demeanor
Excessively tardy in assignment and/or attendance
Not attending class
-- More than two absences?
-- Are they consecutive?
-- Student is ill
Not actively participating in discussion/class
Not turning in/not completing assignments regularly
Failing assignments
-- More than two failures?
-- Are they consecutive?
In danger of failing school/multiple classes
Poor English language skills
Concerns of Academic Dishonesty
 
YesNoDon't Know
Discussing/Showing signs of illness or fatigue
Sleeping more than normal
Behaving erratically (e.g., disrespectful communication, refusing direction, concerning messages/posts/texts, etc.)
Discussing family or friends in turmoil
Exhibiting distracting behaviors
Talking about/smelling of/using excessive amounts of alcohol or drugs
Student Requesting Medical Withdraw