Public Safety Education Department
Student Coaching & Counseling Reply
Must be completed and returned to the issuing instructor the next class meeting.
Student Name: Date:
My perception of the pr
oblem:
My awareness of the seriousness of the problem:
Steps I will i
mplement to correct the problem:
Students Signature_______________________________________________
Instructor Signature______________________________________________
Educational Coordinator Signature__________________________________
This form is due by the next class period or within three days of issuance of the
Public Safety Education Student Coaching & Counseling form.
Public Safety Director notified: yes no
Distribution: Student/Student’s File
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Student Coaching & Counseling Form
The instructor issuing coaching and counseling notifications must submit the proper KCC Retention Alert prior to any actions taken.
Instructor Notice to Student: __ Verbal Written ___ Critical
Student Name
: Date:
Warning i
ssued for:
The seriou
sness of the problem:
Action:
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Notes:
Student
s Signature_______________________________________________
Instructor Issuing Signature_____________________________
Educat
ional Coordinator Signature___________________________________
Date:
__________
Director Notified: yes no
Distribution: Student/Student’s File
Enclosure:
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