[Text Only Version]

Advanced Warning System Faculty Referral Form

November 22, 2009

To enhance student success at Jefferson Community and Technical College, the counselors have developed an Advanced Warning System. This form will be used by faculty for: documenting student concerns at specific intervals throughout the semester; and making referrals in time to help students effectively address academic concerns before the semester ends.

FACULTY: Please complete the following form and select Submit.

Faculty/Student Information

Student's Last Name

Student's First Name

Student's ID#

Instructor Name

Course Name/Number

Campus Course Taught

Referral

Distance Learning

Yes No

Absent more than one day during the first two weeks of classes

Yes No

Consistently Late

Yes No

Does not Participate

Yes No

Leaves early

Yes No

Sleeps

Yes No

Behaves inappropriately

Yes No

Comments (Attendance)

Academic

Under-prepared

Yes No

Lack of preparation/withdrawal from activities

Yes No

Decline in quality of assignments/text performance

Yes No

Difficulty with assignments

Yes No

Difficulty with math assignments

Yes No

Difficulty with writing assigments

Yes No

Difficulty with study skills

Yes No

Comments (Academic)

Non-Academic

Childcare

Yes No

Family conflicts

Yes No

Substance Abuse

Yes No

Transportation

Yes No

Illness

Yes No

Work Conflicts

Yes No

Comments (Non-academic)

Other

Passing my class at this time

Yes No

Discussed my concerns with the student

Yes No

Student needs tutorial assistance

Yes No

Area(s) recommended for tutoring

Image Verification
	Please enter the text from the image [ Refresh Image ] [ What's This? ]

Kentucky Community and Technical College System

Jefferson is a part of the Kentucky Community & Technical College System & is an Equal Opportunity / Affirmative Action Institution.

Kentucky Community & Technical College System
300 North Main
Versailles , KY 40383
(859) 256-3100

Website Disclaimer

If you have problems accessing this page because of a documented disability,
please contact the Access Ability Resource Center .

This site is best viewed with Netscape 7.0 or IE 6.0 or higher and was designed for 800 X 600 resolution.

Jefferson Community & Technical College
109 East Broadway
Louisville, KY 40202
(502) 213-5333