Intervention Success Form

We thank you for taking the time to refer your student to this program. Please take a moment to let me know about your experience.

Instructor’s Name

Class                                                                    

Section

Student’s Name

Have you noticed a difference in the student’s performance since the intervention?

To your knowledge why was this student performing poorly? (check all that apply)
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
                        Other  

How many absences has the student accumulated in your class since initial referral? 

How many assignments has this student missed or not completed?

Is this student in danger of failing your class/ did the student fail your class? 

Yes No

Did you talk with the student regarding his/her class absences and performance after the intervention?
Yes No

Did you feel as though the intervention made a difference?
Yes No

Did you feel like you had good communication with Early Intervention Coordinator throughout the intervention process?
Yes No

Did your student receive a referral to Class Absence Reflection Group?
Yes No

Did your student attend the Class Absence Reflection Group?
Yes No

Did your student receive any other program referrals, to your knowledge?

Yes No

If so, which programs?

Did your student attend these programs, to your knowledge?
Yes No

Overall, were you satisfied with this process?
Yes No

Will you use this service again if necessary?
Yes No

Do you have any thoughts, comments, or suggestions?