Pacific Union College

Academic Intervention Form	*Required fields


*Student First Name	*Student Last Name
*Student ID Number	*Course Number
*Course Title	*Student Grade in Course
What concerns do you have about the student? High rate of absenteeism Excessive tardiness Failure to turn in assignments Submission of poor quality assignments / papers / projects Missed tests, quizzes, or major exams Low test / quiz performance Class disruption, disrespect, etc. Other (explain*) Other: Please explain -
Please explain difficulties the student is currently experiencing in the course:
Comments:
Referral Policy


The staff of the TLC is prepared to help any student you refer to achieve academic success. To assure that neither you nor the Center violates the student's privacy, please be sure to advise the student that you are referring him/her to the Center.
I confirm that the student named above knows that he / she is being referred.
Instructor First Name Instructor Last Name Instructor Phone Instructor E-mail

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