Fillable Caldwell Community College Instructor Referral Form

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Caldwell Community College Instructor Referral Form

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U.S.A. forms for Caldwell Community College and Technical Institute

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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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Caldwell Community College Instructor Referral Form

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Completed 19 February 2020

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