ACADEMIC ALERT FORM



Instructor Name Instructor Email
Student Name Student ID
Course # Course Name
Term Estimated Grade

ACADEMIC

At risk for failure (fill out all that apply):
  1. Student needs assistance building basic skills (math, writing, reading) in order to succeed in your course.
    Specify:


  2. Student needs assistance with specific assignment(s) in order to succeed.
    Enter specific assignment guidelines, due date, name(s) of textbook(s)/reading(s), as applicable.


  3. Student needs assistance building basic academic skills such as test-preperation, note-taking, study skills, or time management skills, in order to succeed in your course and in college overall.
    Specify:


NON-ACADEMIC

Attendance
Punctuality
Completion of assignments
Participation
Preparation
Other:

COMMENTS: