Student Alert Form

Berry College Student Alert Referral Form

Student Name: ID# (if known):

Please indicate which of the following best describes the student's situation.

Lack of attendance in class - Course number:     Last date attended:

           Comments:


Lack of attendance at work - Office and position:

           Comments:


Student appears to be having academic issues that may require assistance. (e.g., failing to turn in assignments; appears to be struggling with assignments or reading, etc.)

           Course:

           Comments:


Student appears to be having personal issues that may require assistance. (e.g. roommate issues, financial issues, interpersonal issues, homesickness, etc.)

           Comments:


Student appears to be having health issues that may require assistance. (e.g. falls asleep in class, frequent requests for health reasons, etc.)

           Comments:


Student appears to be having other problems that may require assistance. (e.g. the student's personal demeanor has changed in some way, etc.)

           Comments:


I have referred the student to the following office(s) for assistance, but I would like someone to follow up with the student.

           Comments:


Faculty or Staff Member Referring Student:

The student is aware that I am making a referral: