This form is to be completed for graduate students with a GPA below 3.00 or have earned less
than a "B" in any course
Name:________ ___________________ Date:_________________
Last First MI
J Number:__________________ Major:_____________________________________
Phone:______________________ E-mail:__________________________________
Current Semester Courses:
________________________________________________________________________
Current GPA Hours Attempted Hours Earned Total Hours Remaining
________________________________________________________________________
List all courses with grades less than "B"
Course Number Course Number Course Number
______________________________________________________
Student's reason (s) for low academic performance: Please check all that apply
Family Responsibilities____ Illness ________Job Responsibility______Other_____
Recommendations/plans to improve academic performance (please be specific):
______________________________________________________________________________
__________________________________________________________________
Approved Disapproved
Student's Signature
__________________________
Advisor's Signature
__________________________
Chairman of Department
__________________________
College Dean
__________________________
Accepted for the Graduate Council
__________________________
Graduate Dean
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