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Online Submission Form

Instructions: Please fill out the information below. You may report a concern about the class as a whole (Illness Alert), or an individual student (Student Alert), or both. You will receive a confirmation message that your form has been submitted. Once submitted, the student you've referred will be asked to meet with his/her Academic Advisor to discuss the problem(s) and possible strategies that will help to improve the student's academic performance. Concerns about overall class attendance (the Illness Alert) will be reported to the Office of Emergency Management. Thank you.

If you have any difficulty with this form, please send an email to: early.alert@uky.edu


ILLNESS ALERT

 

(See http://www.uky.edu/EM/swineflu.htm)

More than 25% of students in my class were absent this week, perhaps due to illness.
  Dates noticed
  In Room
  Building
  Note to instructor: Be sure to complete your name and course/ section below.

 

STUDENT ALERT
Student Last Name
Student First Name
Student ID #

Type of Alert (REQUIRED: please check one or more)
 

  Missed Classes (at least 2-3 in the first weeks)

  Habitually Late
       (more than 10 minutes on a regular basis)

  Homework not submitted

  Homework quality poor

  Poor performance on tests or quizzes

  Disruptive Behavior in class

  Disruptive Behavior in Residence Hall

  Other

Course and Instructor Information
Instructor's Name
Instructor's Email
Course/ Section
Instructor's Phone
Name of Person Completing Form
Additional Comments

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