Early Intervention Initiative Excessive Absence Responders Form

Please complete this form for students reported for excessive class absences who are recipients of your offices’ services or programs.

Responder Name:

Responder Area:
Select One Student Assistance Program - Omar Troutman Student Disability Services - Karen Pettus Multicultural Student Affairs - Rodrick Moore Greek Life - Gena Runion Athletics - Collin Crick Residence Life - North Campus - Helen Fields Residence Life - Central Campus Residence Life - South Campus - Gay Debarbieris

Responder Supervisor:


Student ID:


Student Name:

Type of Intervention Attempted:
yes no  Face to Face intervention
yes no  Telephone (Cell or Room)
yes no  Email-three or more attempts
yes no  Instant message
yes no  Note or Letter to student
yes no  Sent to another responder
                           Name:
yes no  Other
                          Explain:

Date of Intervention:


Has a successful intervention been completed: yes no

If a successful intervention has not been completed please do not continue any further.  Scroll to the bottom and press submit.  Thank you for your participation in this program.

Based on your intervention why was this student performing poorly?
yes no     Student’s health or disabilities
yes no     Family issues or family health
yes no     Transition issues (homesick, Out of State Student, Transfer Student, etc)
yes no     Relationship issues (excessive fighting or break-up)
yes no     Extra curricular student activities
yes no     Alcohol/drugs or partying
yes no     Depression or anxiety issues
yes no     Time management issues
yes no     Financial issues
yes no     Lack of adequate academic/professional direction
yes no     Don't Know
yes no     Other

Based on your intervention which programs have you recommended to the student?
yes no    CAR: Class Absence Reflection Group
yes no    Supplemental Instruction
yes no    ACE: Academic Centers for Excellence
yes no    Math/Writing Center
yes no    CHDC: Counseling and Human Development Center
yes no    Health and Wellness Programs
yes no    Academic Advisor
yes no    Career Center
yes no    Student Health Center
yes no    Student Disability Services
yes no    Student Involvement and Leadership

yes no    Out of State Mentoring Program
yes no    Student Assistance Program
yes no    Other  

Do you recommend that the Coordinator for Early Intervention Initiatives further contact this student?

yes   no

Do you have any additional comments too share regarding this student's situation or the intervention?

Before submitting, please print a copy of this form for your records.