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Academic Intervention Report

Please submit this form if you are a faculty member with a student of concern (academically) during the semester. Please complete one form per student. Information will be shared with the Academic Intervention Committee, the student’s primary advisor, and/or other USC Union staff in order to conduct outreach. Thank you for sharing your concerns and making a difference in the USC Union community.

This form must NOT be used to report emergencies. If you need to report an honor code violation, please complete the Honor Code Violation form instead. If you need to report self-injurious, concerning, or erratic behavior, please submit a referral to the Care Team. If there is a possibility that a student may harm themselves or others dial 911 immediately.  

*Required fields

If you see this don't fill out this input box.

Reporter's Name *

Reporter's Phone Number *

Reporter's Email Address *

Indicate your role and relationship with the student

Faculty: This student is enrolled in my classOther role

Student's Name *

USC ID of Student (can be Banner ID, Username, or UofSC email address) *

What class(es) is the student referral associated with? Please enter one course at a time, and enter course name in only the following format: DEPT COURSE NUMBER SECTION (i.e. MATH 111 701) *

Indicate the concern(s) regarding this student. Check all that apply. *

Academic difficulties due to a disabilityAcademic difficulty due to gaps in foundational skillsDifficulty with professor’s teaching styleEmployment interfering with academicsExperiencing test anxietyGrades don’t match effort or abilityGrades jeopardizing financial aid/scholarshipsMarked decline in performancePoor class attendancePoorly performing in one or more classesUnable to balance work, class, student, and personal/family timeUnsure about academic policiesOther (please provide additional information below

Additional information (please provide as much specific information as possible regarding your referral).

Have you addressed these concerns with the student?

YesNo

Has the student expressed any thoughts of withdrawing from the university?

YesNo

Is the student aware of this referral?

YesNo

Time-frame of this concern

TodayThis semesterOther

If other, provide specific date

Supporting documents may be attached below