Academic Alert Referral Form
Durham Technical Community College is dedicated to helping students achieve academic success. The Academic Alert
Program is designed to help you offer assistance to your students who may be in danger of not completing your course
successfully. If you send this form to the Academic Alert tutor, we will contact your student to schedule a one-on-one
tutoring appointment.
Date: __________________ Student’s Name: ________________________________________________
Student’s Colleague ID: __
Course and Section Number: _______________________________________________________________
Student’s Current Phone Number: ___________________________________________________________
Student’s Email Address: ___________________________________________________________________
Instructor’s Name (print):_____________________________ Signature: _____________________________
☐ Use my email signature Instructor’s contact information: _________________________________
This student is being referred for Academic Alert due to the followingissue(s): (Please check all that apply)
☐ Is struggling with reading sk
ills ☐ H
as difficulty with research sk
ills
☐ Is struggling with writing skills ☐ Has difficulty with oral communication skills
☐ I
s struggling with math sk
ills ☐ V
iolated Academic Honesty polic
y
☐ H
as difficulty with study sk
ills ☐ Ha
s not turned in assignment
s
☐ O
ther ___________________________
__
Please include other pertinent referral information below:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Be sure to notify the student that you are referring him or her for assistance. Send this form to the Academic Alert
tutor in the Center for Academic Excellence, Wynn Center, room 10-308, or attach it in an email to the Center for
Academic Excellence. For questions, contact LaDelta Williams, ext 2401.
For non-academic issues, please refer to the Counseling Referral Process.
Revised8/2017
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