Early Alert Referral Form

Use this form to refer students directly to learning skills coordinators on the Castlegar, Tenth Street and Silver King campuses.

Learning skills coordinators will reach out to students and connect them with supports available at Selkirk College.

Instructor Name Instructor Name First Last
Course Name/Number
Campus:

Campus: Tenth Street Campus (Darcy Falkenhagen) Silver King Campus & Victoria Street Campus (Laurie Jarvis) Castlegar Campus (Sarah Somerville) Trail Campus (Sarah Somerville)
Student Name Student Name First Last
Student Number
I am referring this student to early alert because:

I am referring this student to early alert because: They have received low grades on assignment(s)/test(s) They have low attendance, are often late, or haven’t logged onto Moodle They appear to have deteriorated mental health (e.g., mood, sleepiness, isolation, anxiety, aggression, depression) They appear to be underprepared for the academic rigour of the program (e.g., study skills, note taking, computer skills)
Additional comments:
Action Taken
As the instructor, I have

As the instructor, I have Discussed the issue with the student Advised the student about the Selkirk College services available Invited SAS into my class to present their support services
Additional comments:
Student Email
Or

Student Phone Number Or

Student Phone Number - ### - ### ####
Click here if this is an online/distance course or program

Click here if this is an online/distance course or program Online/Distance
Symptoms

Symptoms Missed a significant assignment Failed more than one test Poor study skills Student appears unprepared for class rigour Does not come to class prepared Sleeping in class Late to class Disruptive behaviour Missed two or more classes Appears to be distressed Poor attitude/lack of motivation Changes in demeanor - anxiety, depression, aggression Comments of concern from other students
If none of the issues above apply, or there is other relevant information, please use the comment box below:
I am filling this out for:

Early Alert Referral Form

Early Alert Referral Form

Action Taken