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| Student First Name: |
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| Student Last Name: |
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| Student ID number: |
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| Course Name: |
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| Section Number: |
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| Instructor's Name: |
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| Have you spoken directly with the student? |
| Yes No - If yes, how many times? |
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| The above named student is being referred for assistance in the following area(s) – please check all that apply |
| Low test scores |
Student not doing homework |
| Poor study habits |
Poor classroom attendance |
| Needs financial assistance |
Student does not have books |
| Child care issues |
Highly recommend tutoring |
| Poor classroom participation |
Disruptive in class |
| Poor attention span in class |
Student is late to class |
| Student leaves class early |
Cell phone use is an issue |
| Needs writing assistance |
Not prepared for class |
| Talks too much (not class-related) |
Needs English/reading assistance |
| Needs bilingual assistance |
Needs spelling assistance |
| Needs vocabulary assistance |
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| Other: |
| Please make any additional comments or recommendations you feel would assist us in making the best referral |
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| Thank you! |
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