EARLY ALERT FORM

Student Success Programs - Early Alert Program

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As a faculty member at Eastern Oregon University, you are often the first to notice when students are struggling to adjust to college. If a student is doing unsatisfactory work in your course or appears to be struggling in other ways that would put her/him at risk for leaving EOU, please fill out this form, check the appropriate boxes, provide additional information (if any), and click on the “Submit Early Alert Referral Form Now” button at the bottom of this document.

Upon receipt of the referral, the Director of Student Relations or Core 101 Coordinator will contact the student to schedule a meeting to discuss her/his success. This contact may include referrals to on-campus and/or off-campus resources.

Early Alert Program Information

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Early Alert Referral Form
Student First Name:
Student Last Name:
Course Reference Number:
Course Prefix Number:
Instructor / Referee Name:
Instructor / Referee E-mail:
Academic Concerns (Please Check All That Apply)
	Excessive absences
	Chronic tardiness
	Inadequate background / knowledge for this course
	Apparent lack of interest
	Some or all significant assignments late or missing
	All assignments missing
	Missing exams
	Poor examination results
	Class disruption, common disrespect
Other Conduct Judged Inappropriate:
Comments or Other Academic Concerns:
Student Life Concerns (Please check all that apply)
	Academic decision-making problems, motivation, success
	Complaints of harassment or discrimination
	Serious medical condition (potential medical withdrawal)
	Financial problems
	Learning problems
	Personal or family problems
	Residence Life issues
	Finding a niche at EOU (getting connected)
	Suspected substance abuse
	Time management problems
Comments or other student life concerns:

Course of Action (please identify course of action already taken):
NOTE: EOU is committed to helping students achieve academic success. To assure that neither you nor the University violates the student’s privacy, please be sure to advise the student that you are referring her or him to the Director of Student Relations.
	I have conveyed my concerns to the student but we have been unable to meet to discuss the situation.
	The student and I have discussed the above situation.
Comments or other action - please describe:
If the options on this form do not fulfill your needs, please feel free to contact the Director of Student Relations at 541-962-3476 to discuss your concerns and consider a course of action.

This referral form was adapted from the University of Puget Sound, Academic Advising and Registrar’s Office, Triad Program and Student Alert Group website at http://www.ups.edu.

Student Relations Office

Office of Student Affairs

Eastern Oregon University

HUB 321B

La Grande, OR 97850

Phone: 541-962-3476

Eastern Oregon University - One University Boulevard - La Grande, OR 97850-2899 - Phone: 541-962-3378