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Pathways Early Alert Form
EmailMeForm
Date
MM
/
DD
/
YYYY
Student
*
Professor
*
Class Year
First-Year
Second-Year
Third-Year
Fourth-Year
Course
Course Grade (If Available)
Nature of Concern (Select All That Apply)
Level of work seems too difficult
Lack of application
Problem with basic study skills
Writing deficiency
Student considering withdrawing
Irregular attendance at class or work
Evidence of personal problems (e.g., home, medical)
Substance abuse problems
Major or career indecision
Housing concern (roommate or living situation)
Other - if so, include in comments field
Have you discussed your concern with the student?
Yes
No
Is the student aware of your referral?
Yes
No
If the student is unaware of the referral, may we use your name?
Yes
No
Additional Comments
Contact Information
Phone: 319-352-8615
Fax: 319-352-8365
100 Wartburg Blvd.