TRiO Early Warning System Referral Form

Instructor Name:

Instructor Email:

Course Title:

Name of Student you are Referring:

Area(s) of Concern

Is attendance a problem?:

Yes

No

If yes, how many classes missed?:

1

2

3 or more

Low test/quiz scores?:

Yes

No

If yes, how many test/quizzes remain for the semester?:

1

2

3 or more

Assignment completion?:

Yes

No

Study Skills?:

Yes

No

Other? (please specify):

Comments:

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Program Director TRiO
Benjamin Tobias
330-494-6170 ext. 4173
Room #: B230a