Academic Intervention Referral Form

This form is to be used for referring students to the Academic Intervention Team regarding concerns that are related to a student’s academic success. The more information you can give us, the better our ability to provide quick and effective outreach and support to the student. Once you have referred a student to us, please feel free to provide additional information at any time by emailing us at intervention@TC3.edu. If you have uncertainty about whether this is the appropriate group to which to convey your concern, please know that we will redirect your referral if appropriate.

Referrer information

Your name

Your TC3 email

Relationship to student

   Instructor
   Advisor
   Coach
   Other, please identify

Student information

Student name

TC3 ID (if known)

Concerns

Attendance

Excessive/unexplained absences
Regularly arrives to class late and/or leaves early

Please provide details about the student's attendance

Academic performance

   Unprepared for class
   Unengaged in class
   Missed/late assignments
   Missed quizzes/exams
   Low grades
   Student struggles to keep pace with class

Please provide details about the student's performance

Other concerns

Please describe any other concerns you have about the student

Actions previously taken

What course(s) of action have you already taken to address your concerns with this student?

   Met with student
   Suggested that student use Baker Center tutoring services
   Suggested that student use TC3 counseling services
   Talked about academic skills and/or study strategies

Action details, and/or additional information