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Academic Support Center
Instructor Referral Form
To: _______________________________________ Date: __________________________
Course Instructor
From: Jennifer Teague, Academic Support Technician, Academic Support Center
I recommend that _____________________________, _______________________, receive
Student Name Student ID Number
tutoring for the following class: ____________________________________________________
Course Name and Number
This student needs help with the following topics: (please list specific course content)
The student’s current grade average (if available): _____________________________________
Total Times Tardy: ________________________ Total Times Absent: _____________________
_______________________________ **I would like a report of this student’s time. ___ Yes ___ No
Instructor
To the Instructor:
To the Student:
o You may refer students to the ASC for any type of assistance. o Your instructor must sign this form.
o Please identify the area of remediation for the student. o Bring this completed form with you to the ASC.
o Please sign and complete Class information.
o Have the student bring the signed form to the ASC.
In order for students to take advantage of the assistance and equipment available in the ASC, a
signed referral is required upon their first visit to the center. In order to make this process as
simple as possible, there are a number of ways to refer students to the ASC.
First, students may pick up blank forms from the ASC in order to obtain an instructor’s
signature.
Second, instructors may print, complete, and sign these pdf forms and send them to the
ASC along with the student who needs assistance.
Finally, for those instructors who may only work with students online, these fillable pdfs
may be completed on a computer and submitted via email to (ASC/Caldwell@cccti.edu
or ASC/Watauga@cccti.edu) in advance of the student’s visit.
Should you have questions or concerns about the referral process, please contact the
ASC (ext. 2725 or 297-3811 ext. 5295)
Please return forms to Jennifer Teague, Academic Support Center, F-146
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